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Medical Record Documentation and Legal. Aspects Appropriate to Nursing Assistants. 2 In-Service Hours. Course Objectives: 1. Describe four forms commonly ...
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We have heard it said over and over again, “If you did not document it, it was not done”. A medical record is the patient’s history, of all care that is provided. If it is not recorded, it did not happen. If it is recorded incorrectly it happened incorrectly. As a health official you don’t want to be the indivial trying to explain something that didn’t happen. This is why it is so important to be accurate when documenting. Four most commonly used forms with particular importance are:
Legal Implications Documentation provides important legal protection. Admissible in court, the patient’s medical record must be documented in an accurate, complete, systematic, logical, concise, and timely manner. Courts will view the documentation in the medical record as proof and verification to patient care. By showing that the individual under your care received quality, an equal care, a well documented record can, and will most likely protect you legally. The medical record is a legal document. It is also regarded as highly confidential, especially in light of the new HIPAA regulations. In the event of a medical malpractice case, the medical record may be used to provide the court with evidence about a patient’s condition and treatments. In a malpractice case, the jurors usually see the medical record as the best evidence of what really happened. For this reason, all documentation should be neatly written. Not legible handwriting is handwriting that cannot be read or understood by others. This would account for sloppy writing, and often misspelled words and poor grammar. Not legible or poorly written documentation makes you look careless and distracted. Take the time to write neat and clear. Avoid words that are unnecessary or very long. If you don’t know the definition to a word dont write it. When you abbreviate, make sure it is a standard abbreviation, not one that you invented with no possibility of having more than one meaning.
message, and response. Protect your self
Types of charting Regardless of the system of charting you use, it must include the nursing process as a guideline.
Narrative charting The nurse documents in chronological order the events that took place throughout the shift. Narrative charting takes a lot of time 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 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
Care Plans Most care plan formats have three columns, one for the nursing diagnosis, one for the interventions, and one for the expected outcome. The nurse must develop a care plan for each client usually within a specified period of time after the client arrives to the facility. They are generally initiated upon admission. Standardized care plans are preprinted care plans to help save time for the nurse. They must be individualized to fit the needs of each patient separately and individually. Critical pathways or health care maps are usually preprinted care plans. They include nursing actions for a client with a specific medical diagnosis. The specify care that should be given on a daily basis including, but not limited to diet, medications, activity, treatments, ect. Pathways are popular with managed care becoming about more and more. Kardexes Kardexes are useful, but need to be looked at and up to date to be of any value. The card system is available to all staff that needs information at a glance to what is important with the patient. The cards are written in pencil so they can be updated appropriately and easily.
Things to Remember We have learned a lot about proper documentation. Here are a few other things to consider: The following mistakes can cause legal problems: