Charting, when, why, and how

[med_cat]

...aka, "you finished your report to the next shift an hour ago, what are you still doing here?!" "...charting..."
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Here you are, acelightning and browngirl

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A condensed version of the discussion we have in class:

Why do we document?

-To communicate with other members of healthcare team

-To communicate with subsequent shifts

-Legal purposes

Documentation should be:

Factual

Concise

Timely

Without unapproved abbreviations

(can tell you some good stories about those, if you'd like)

Formats:

Narrative

SOAP, SOAPIE, etc.

PIE/PGIE

FOCUS DAR

etc.

Example of narrative note:

55 y.o. female, S/P L THR, POD #1, medicated for pain x3 this 7a-7p shift per prn order with relief. No other complaints, NAD. L hip dsg D/I, hemovac in place, moderate amt. of sanguineous drainage. Pt was OOB to chair x 3 hrs.

Hope this helps; feel free to ask for more details

Two videos below.

Can share other stories and videos about medical errors, btw, if anybody's interested, let me know...
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Comments

[acelightning.livejournal.com]

[med_cat]

Charming list...