This journal is mostly public because most of it contains poetry, quotations, pictures, jokes, videos, and news (medical and otherwise). If you like what you see, you are welcome to drop by, anytime. I update frequently.

Layout by tessisamess

Customized by penaltywaltz

Tags

View all Tags

Layout By

Layout

Previous | Next
med_cat: (Stethoscope)
med_cat: (Stethoscope)

Charting, when, why, and how

Nov. 29th, 2017 at 7:23 PM
med_cat: (Stethoscope)
...aka, "you finished your report to the next shift an hour ago, what are you still doing here?!" "...charting..."
~~
Here you are, [livejournal.com profile] acelightning and [livejournal.com profile] browngirl

~~
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...
~~


Tags: , ,

Comments

(Leave a comment)
[identity profile] acelightning.livejournal.com
Dec. 4th, 2017 03:52 am (UTC)

med_cat: (dog and book)
[personal profile] med_cat
Dec. 4th, 2017 10:37 am (UTC)
Charming list...
(Leave a comment)