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Charting defensively
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How to chart
What to chart
When to chart
Who to chart
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Stick to the facts Recard only what you SEE, HEAR, SMELL,
FEEL, MEASURE AND COUNT
NOT what you infer, conclude, infer or assume. For example: if a patient pulled out his I.V line but
you didnt witness it, write: Found pt, arm board andbed linens covered with blood. I.V line and venipuncture
device were untaped and hanging free.
If the patient says he pulled out his I.V. Line,record that.
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Objectively describe patients behavior: Pt found pacing back and forth in his room, muttering
phrases such as, Ill take care of him my way while
punching one hand into the other.Avoid using expressions such as appears
spaced out, flying high, exhibiting bizarre
behavior, or using obscenities.
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Use only approved abbreviations andexpress your observations in quantifiableterms.
Wrong: output adequate; Pt. Appears to be inpain Right: output 1200 ml; Pt. Requestedpain medication after complaining of lower
back pain radiating to his R) leg which he rated7 out of 10 on the visual analogue scale (VAS)
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Ex:Complaining of pain at L) antecutital I.V. Site at
1000. Pain rated on VAS scale 3/10. Dressing
removed. Redness 2 cm wide around I.V. Insertionsite. No drainage. Quarter-sized area of edemaabove insertion site, I.V. Removed, site cleanedwith povidone iodine and sterile dressing applied.
Warm compress applied to site x20 min. Dr. JohnSmith notified. Acetaminophen 650 mg given POat 1015. Pt now reports pain 0/10 on VAS. M.Doherty,RN
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Dont use language that suggests a
negative atttitude toward the patient. Ex:obstinate, obnoxious, drunk, bizarre or abusive.
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EX:I attempted to perform the daily abdominal dressing
change, but pt stated, this doenst need to bedone everyday. It doesnt hurt and I dont want you
to touch it. Leave me alone. I explained theimportance of monitoring and cleaning theincision and offered an analgesic to be given 20min before dressing would be chanegd. Pt. Became
agitated and still refused. Dr. B. Humbert notifiedthat incisional site was not assessed nor wasdressing changed and that patient was agitated.
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Significant situations out-of-the-ordinarysituations, critical situations.
Chart complete assessment dataDuring initial assessment, focus on the
patients reason for seeking care, and thenfollow up on all other problems hementions. Be sure to chart everything youdo as well as why.
Document discharge instructions.
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Document nursing care when youcomplete care or shortly afterward.
Never document ahead of time yournotes will be inaccurate and youll leave
out information about the patients
response to treatment.
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Never ask another nurse to complete yourcharting (and never complete anothernurses charting).
If the other nurse makes an error ormisinterprets information, the patient canbe harmed.
Delegated charting destroys the credibilityand value of the medical record both in thefacility and in court.
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Dont record staffing problemsDont record staff conflicts.Dont mention incident reportsDont use words associated with errors (i.e:
by mistake, accidentally, somehow,unintentionally, miscalculated and confusing)
Dont name a second patient. (Use ptsinitials, room and bed number or the word
roommate)Dont chart casual conversations with
colleagues.
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Lippincott Williams and Wilkins. (2006).Charting made incredibly easy(3rd ed.).Philadelphia, PA: Author
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