The Art of Charting - NVHCA · • Significant appetite changes • Weight change triggers •...
Transcript of The Art of Charting - NVHCA · • Significant appetite changes • Weight change triggers •...
The Art of Charting
What is Charting?Charting is vital for several reasons.
• It is the basis for communication between all healthcare professionals who care for the resident.
• Doctors, Nurses, Social Services, RD’s and support staff use it to create a specific level of care provided for the resident for optimum results.
• It is also a tool used to decide among various treatment options, to determine level of reimbursement for nursing services, and to determine the effectiveness
of interventions provided.
The resident’s physical, mental, social and spiritual conditionis demonstrated through complete documentation.
Charting is?A legal medical record that can be used in
the court of law.
The main mechanism by which state surveyors, attorneys, and the attorney’s experts will evaluate the quality of care
provided by the nursing home
Charting Rules 101
#1 If it’s not charted it’s not done.
#2 Always chart the problem then the solution.
Pit Falls of Charting
Diets don’t match upOn tray ticket, notes and
Computer application
Sloppy hand writing
Too little information
Using previous notes for assessments
Actual Charting
• “Patient was alive but without permission.”
• “Resident is eating less than 25% but has a good appetite.”
• “Patient had waffles for breakfast and anorexia for lunch.”
• “Resident is alert but could not speak to her because she was asleep”
• “Healthy-appearing, decrepit 69-year-old male, mentally alert but forgetful.”
• “Patient was alert and unresponsive.”
• “The patient gets hives from contrasts, strawberries and shrimps and also
two of her children.”
• “Resident has issues and bouts of craziness ”
• “Patient eats death threats for breakfast.”
• “Resident has issues”
Significant Nutritional Changes and Conditions that fail to get documented• Significant appetite changes• Weight change triggers
• Residents complaints of oral pain, chewing or swallowing problems (Procedure to chart)• Significant edema in resident fluctuating weights up and down drastically
• Lack of any wound supplements• Food allergies not documented• Changes in food preferences
• No mention of dialysis treatments• Decrease in tube feeding consumption
• Mental status• Diarrhea
• Needs to be fed• ADL eating utensils and drinking cups
• Denture and oral status• Correct diet and liquid status
• Residents receive poor quality of care• Supporting staff don’t see the whole nutritional picture of the resident• Insufficient nutritional care provided• Residents could die, nursing facilities sued, court proceeding ensue, fines implemented,
loss of facility reputation, money and jobs
TYPES OF CHARTINGInitial 5 day Admit note14 day note, 30, 60, 90, Significant Changes
(Change of therapy, Weight, Hospice care, Palliative Care, Feeder)
Quarterly noteAnnual note
Being discharged to the hospitalBeing re-admittedOral Status change
Eating behavior change, ADL devices addedObservation notesResident expired
The 7 Day Story
Initial Nutritional Assessment
Resident___________________________________ Admit Date__________________ Age__________
Diet Order: __________________________Primary Diagnosis________________________________
Physical Characteristics: Sex:___ M___F Ht:________in. Wt_____LBS. IBW Range_______ IBW: Below__ Above__
Phys. Observation: Week___ Edema +_____ Wounds_______ Paralysis____ Amputation______
Dental: Own Teeth? ____Yes ____No: Broken___ Missing ____Likely Cavities_____ No Teeth___
Denture Status: Full Set____ Yes___ No/ Upper____ Lower____/Partial: Yes___ NO____/____Upper ____Lower
Will not wear dentures _______ Wears dentures at times ________ Wears to eat only_______
Food Consistency: Puree____ Mech. Soft____ Reg.____ Chopped____ Ground Meats____ Finger Foods____
Liquid consistency: Regular Thin____ Nectar Thick____ Honey Thick____ Pudding Thick _____
Ability to Feed: No Assist _____ Set-up Assist _____ Fed by staff____ Monitored by staff____
Assist Devices: Divider plate____ Weighted utensil___ ADL Cup____ Curved utensil_____
Other: ____________________________________________________________________
Chewing/Swallowing
Chewing Problems: ____ NO_____ Yes: Pain____ Irritation____ Ulcers____
Swallowing Problems: ____NO ____ Yes: Pain____ Difficult y____ Coughing____ Gagging____
Mental Observations: Confused______ Combative______ Non Responsive ______ Alert____ Disoriented______
Ambulation: Independent____ With Assist____ Wheel Chair____ Wheel Chair Pedal____ No Ambulation___
Food Preferences/Intolerances
Location of meals: ____Dining Room ____ Room
Food Likes: ____________________________________________________________________________________
Food Dislikes:__________________________________________________________________________________
Food Intolerances/ Allergies: _____________________________________________________________________
Comments:____________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Interviewed By: ____________________________________ ___________________Date:____________________
Physicians OrdersOrderDate6
/5
Start Date
OrderType
Order No.
IntervalCode
Time Code
Orders
12/22/16 12/22/16 Med 31 QD QHS J30.9 Allergic rhinitis. Singulair 10 MG tablet po Q HS Generic Montelukast Sodium
3/03/17 3/04/17 MED 72 QD QHS E87.6 hypokalemia Potassium CL 20 meq. tab. Give 2 tabs PO qday
6/25/18 6/26/18 MED 155 QD QD8 Vit. Deficiency, Vit D3 1,000 unit tab. 1 tab qday
4/5/17 4/5/17 DTY 146 QD TIDW/M
Nas; Extra gravy w/meals
5/15/17 5/15/17 MED 212 QD QHs Remeron 7.5 mg QHS D/T depression.
3/18/18 3/18/18 SUP 146 QD TIDW/M
House supplement 4oz. PO TID with meals
12/22/16 12/22/16 MED 23 QD QHS Flomax 0.4 capsule PO Q HS
12/22/16 12/22/16 MED 28 QD QHS Latanoprost 0.005% eye drops 1 GTT in each eye Q HS
8/03/18 8/03/18 MED 161 PRN EPRN Flu vaccine 0.5 ml IM Q Fall When available
7/12/16 7/12/16 MED 53 QD QHS Lasix 40 mg. D/T Edema QHS
7/5/18 7/5/18 MED 21 QD BID Cranberry 450 MG TAB BID
2/14/16 2/14/16 MED 122 PRN EPRN Tylenol 200 mg. TAB AS Needed for pain
12/22/16 12/22/16 MED 26 QD BID84 Colace 100MG Capsule. 1 capsule PO Q HS for Constipation
3/18/18 3/18/18 SUP 145 QD QD7 4 oz. Prune juice PO with Breakfast
12/22/16 12/22/106 MED 28 QD QHS Flomax 0.4 MG capsule PO Q HS D/T Retention of Urine
FACTS OF THE STORYOrientation
DietTextureLiquids
SupplementsWound supplements
Oral statusChewing, Swallowing or Mouth pain
Admit weight or Current weightEating percentage and eating habits
VitaminsDiuretics
Appetite Supplements Any proactive care measures
Vital Lab DataLikes and Dislikes
Story Note FormatIntroduction
Basic Facts
Care Plan
Conclusion
The IntroductionBeing that the reader does not know
anything about the resident yet. Your note shouldtell the reader who the resident is in general, to get to
know themEx: Is the resident alert and can they answer basic questions.
Are they friendly, talkative something about them that defines them and sticks out
Basic Facts of the ResidentWeight, height, diet, liquids, eating habits,
Vitamins, diuretics, where they eat, do they feed themselves,Oral status, PO %, supplements, stimulants, ADL’s etc.
Care Plan• Significant weight loss/gain action• Oral concerns addressed• Eating habits being qued, monitored etc.• Preferences noted and implemented• Dislikes noted and implemented• Diminished PO addressed with snacks,
alternate foods, supplements • ADL needs activated• Decreased hydration addressed• RD education implemented
What will my department do to
address any issues noted from the
Facts
How often will the precautions be done
What are the goals; if any do you have
for the residents nutritional needs.
Rules to Oral Charting1. Always physically go see a resident and check on their oral status
2. Never go by previous notes of other staff workers
3. If the resident is not responsive then ask the CNA or Nurse to help you
determine if they have any teeth, dentures, partials and if they have
any discomfort or pain during meals.
4. At an assessment if you ask a resident if they have any pain, chewing or
swallowing problems; and they say yes,
You must first: Tell the Nurse so they can verify
Then the Social Service director so they can also verify
Do not chart anything until you find out what is being done.
5. The SS director will investigate with the LPN and check the validity of the statement of
the resident then determine if the resident needs a dental appointment.
6. Once the SS director speaks with the resident, nurse, ST or CNA; she may make an
appointment with the dentist. At that point you can make a note in the chart that
the resident has an appointment to see a dentist on what ever date.
7. Once the resident has come back from the dental appointment the SS director should
give you the paper work which states the results of what action was taken to address
the resident oral issue.
8. You should then chart about what action as taken to address the resident oral issue.
Resident - Mary Butterfluffanutter• Non-responsive
• On a NAS Pureed diet with Nectar thickened liquids• Gets HI Call 4 oz. TID and Mighty Shakes BID at snack pass
• Started on Remeron QID recently• Allergic to shellfish
• Takes Liqua Cell BID for Wound healing• Has own teeth with upper partial and missing teeth
• No Chewing swallowing or mouth pain• Height 62 inches, 112lbs.
• Current weight is 112 lbs. and has had a significant weight loss of 6 lbs.in 30 days• On weekly weights
• Eats 25% to 50% of meals and snacks • Refuses some meals
• Has to be qued for optimum PO and eats in the restorative dining room• Takes a MVI + Minerals and VIT C for wound healing Qday
• Likes oatmeal dislikes cabbage and brussels spouts
Raising the bar. One smile at a time
Presented by: Reynold LandryExecutive Chef/ CDM CFPP CF-PS