Live Stream Search: NFL, UFC, NBA, MLB, Rugby, Soccer, FIBA and Other Sports » Nurses Progress Notes http://nurseonline.org Nursing Your Web Content Wed, 08 Sep 2010 02:38:50 +0000 en hourly 1 http://wordpress.org/?v=abc Types of Nursing Charting l Patient Progress Notes http://nurseonline.org/types-of-nursing-charting-l-patient-progress-notes/ http://nurseonline.org/types-of-nursing-charting-l-patient-progress-notes/#comments Wed, 23 Sep 2009 03:10:00 +0000 Site Admin http://nurseonline.org/types-of-nursing-charting-l-patient-progress-notes/ Posted by : Rey-Ryan P. Mapiles RN

Types of charting
Regardless of the system of charting you use, it must include the nursing process as a guideline.
1. Assessment
2. Planning
3. Implementation
4. Evaluation

Assessment includes observing the patient for signs and symptoms that may indicate actual or potential problems.
Planning includes developing a plan of care directed at preventing, or resolving identified client problems or issues.
Implementation (or intervention) of the plan that has been developed includes the specific action that the nurse needs to take to accomplish the plan.
Evaluation determines whether or not the goal was met in identifying if the plan of care was effective in preventing, or resolving the problem.

Narrative charting
The nurse documents in chronological order the events that took place throughout the shift. Narrative charting is time consuming, so make certain your notes are legible and clear to understand by all who reads them.

A note should be made at least every two hours.

SOAP Notes
This method is preferred by many nurses. It stands for Subjective data, Objective data, Assessment, and Plan. Sometimes it can be referred to as SOAPIE or SOAPIER, in which the “I” indicates implementation and “E” indicated Evaluation. When an “R” is included, this indicates Revision.

APIE
More commonly known as “Pie Charting”
Assessment, Plan, Intervention (or implementation), and Evaluation. It is more concise in the aspect that the nurse will indicate subjective and objective data in the assessment section, what will be done in the plan, the intervention and the outcome. As it follows through in A, P, I, E format.

Flow Sheets
Also known as graphic sheets, or graphic records. These are a quick way to document. They need to be used CAREFULLY, as some areas do not apply to all patients. Avoid leaving any boxes unmarked, and individualize it to meet your patients needs.

Focus Charting
The term focus was developed to encourage the nurse to view the client’s status from a positive perspective rather than a negative perspective. The system uses three columns to indicate date/time, focus, and progress note.

The progress note portion includes DAR( date, time, response)
Date/time focus progress note
Date:
Action:
Response:

Charting by exception
Also known as CBE. A system of charting in which only significant information, findings, or exceptions are documented.

Nursebitz.com ALERT: No matter which method you prefer, or your facility uses, make sure that the content is addressing the proper do’s and don’ts for charting.

]]> http://nurseonline.org/types-of-nursing-charting-l-patient-progress-notes/feed/ 0 do not’s of charting in Patient’s Medical Record http://nurseonline.org/do-not%e2%80%99s-of-charting-in-patients-medical-record/ http://nurseonline.org/do-not%e2%80%99s-of-charting-in-patients-medical-record/#comments Wed, 23 Sep 2009 03:03:00 +0000 Site Admin http://nurseonline.org/do-not%e2%80%99s-of-charting-in-patients-medical-record/ Posted by: Rey-Ryan P. Mapiles RN

The do not’s of charting are very important also:

1. Don’t chart a symptom such as “c/o Pain” without also writing what you did about it.
2. Don’t alter a chart….this is a criminal offense.
3. Don’t add information at a later date without indicating that you did so.
4. Don’t date the entry so that it appears to have been written at an earlier time.
5. Don’t use shorthand or abbreviations that are not standard.
6. Don’t write vague descriptions such as “ large amount of drainage”
7. Don’t make excuses, such as “meds not given because not available.”
8. Don’t chart what someone else says unless you use quotations and state who said it.
9. Don’t chart an opinion.
10. Don’t use words that suggest a negative attitude, such as “weird” or “nasty”
11. Don’t chart ahead of time. If something happens it will look bad to go back and make that
correction.
12. Misspelled words and bad grammar are as bad as illegible handwriting.
13. Don’t record staffing problems.
14. Don’t document that an incident report was completed.
15. Don’t record staff conflicts.

Charting care that was not given is fraud. It is punishable by the law and can land you in court, or put your license in jeopardy.

Nursebitz.co ALERT: if you make a mistake, draw a line through the error, and indicate it as an error, and then initial it. Do not write “oops” or “sorry” or draw a happy or sad face in the margin, or any where on the document. This is unprofessional and inappropriate. Don’t leave any blank spaces. Never save a space for a colleague who forgot to chart.

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