Forms
What form could be describe as traditional and is labour intensive?
Narrative Charting
How should you correct an error when charting?
Draw a straight line, mark error, date and time and initial.
What is documentation in nursing?
It refers to written or electronic client information obtained through the nursing process (Association of Registered Nurses of Newfoundland and Labrador, 2010)
What should be documented?
Actions and Interactions
What type of charting is the SOAP method?
Problem Oriented
How should the date be written.
Follow policy of institution. If no policy write day-month-year.
What is the primary purpose of charting in nursing?
Communication Tool
Should I only document what I do?
Observations!
What forms are commonly used when using the charting by exception method?
Flow Sheets
Is it acceptable to use abbreviations?
You should use only abbreviations approved by the institution.
Can you think of another common purpose?
Permanent record of care.
When should you chart results or outcomes?
Anytime an action or intervention is taken the result or outcomes must be documented.
What Charting System will you use?
The charting system you use will be determined by the institution where you practice.
Does spelling count?
Spelling and grammar avoid possible miscommunications and lend credibility.
Is it important to not improvements and outcomes?
Yes. Your charting track progress, is evidence of continuity of care and the nursing process.
I gave a prn medication. What if anything should be charted?
Why? How much? Effectiveness?
What type of charting should students learn?
All of them!
How often should you chart?
Charting should be sequential and as timely as possible.
Charting effects future care. How?
Nursing Research
My clients vital signs are normal. How and what should I chart?
Record the V/S on the institutions flow sheet. The method of charting used will determine if additional documentation is required.