Quick Tips for Charting
The letters EMR stands for.
What is Electronic Medical Record
Provides proof of your work and care that has been provided to a patient.
What is nursing documentation
Documentation that is easily read and understood
What is chartiing is legible ?
Charting care that you have not done.
What is fraud?
Tylenol 250 mg ordered and you gave 750 mg x 4 doses on your shift. In the AM the patient's liver enzymes are completely elevated and now the patient needs a liver transplant.
What is a medication error?
Documenting in a particular order.
What is documenting in a chronological format?
Pt states to the nurse" I feel nauseated" and she uses that sentence when documenting in the EMR.
What is charting patient symptoms in their patient’s own words, communication gestures or non-verbal cues as much as possible
Located in patient's rooms, hallways and workstations.
What is computers or WOW?
Nurse wants to document: patient in room being silly and I was LMHO with the mom.
What is do not use shorthand or abbreviations that are not widely accepted
RN asks the PCA to change the patient's dressing and notify her of the patient's drainage.
What is negligent or inappropriate delegation and supervision
0930AM:Dressing change by Dr. Jackson. Pt tolerated it well.
1100AM:RN sits down to open chart and document.
What is charting care at the time it was provided or w/in a 2 hour time frame
RN documents:1100: After ambulating my dizzy pt to BR,I helped pt back to bed with side rails up, bed in low position and mom at bedside.
What is charting precautions or preventive measures used?
Each facility has a list of these that are approved to use when charting.
What are abbreviations and terms?
Counseled and terminated for changing the time an assessment and medications were given after the patient seized and coded to cover up the actual it was done.
What is a criminal offense?
RN is found passed out in the bathroom with a bottle of alcohol and container of oxycodone on the floor beside him.
What is working while impaired, whether by inadequate sleep or controlled substances
Data that helps you enhance patient safety, evaluate care quality, maximize efficiency, and serves as a standard form of documentation that can be shared by everyone on the healthcare team.
What is an Electronic Medical Record
1500:PO Tylenol given for temp 101.2
1600: Pt's temp retaken and decreased to 99.5
What is charting the time you gave a medication, the administration route, and the patient's response?
These two things are recorded automatically on the computer.
What is Date and Time?
Pt admitted for anorexia. After lunch you chart:Pt did not eat enough food at lunch. The plate had most of the food left on it.
What is chart objective facts, not your interpretations or opinions
Admission orders include to place patient on telemetry monitoring due to irregular HR. RN goes to lunch and plans to attach the patient when she returns. Pt has bradycardia spell and codes while RN is in the cafeteria and is now in the PICU.
What is fail to monitor and/or assess?
Do this to add additional information to an entry after completion of charting
What is charting with the notation "late entry"
RN in room with 8 y/o patient for 20 mins to give scheduled medication. Patient will not take antibiotic because she says it tastes nasty. Primary MD paged.
What is patient refusal to take a medication or allow a treatment and MD needs to be notified.
This is private for the user, changed frequently, and should not be shared with anyone.
What is a password?
0705:Right after report before going in Lilah's room, RN charts pt seen and examined. Awake, alert and playful. Phenobarbital given that's due at 9:00am.
0800: PCA goes in for VS and finds patient pale, blue and non-reponsive.
What is DO NOT document assessments, medications or treatments before they are given or completed
RN reports to Dr. Jackson his patient M. Jones in RM 305 has an elevated BP 180/110 and needs nifedipine. Patient M. Johnson in 308 has the BP of 180/110. M. Jones in 305 gets nifedipine and BP bottoms out and patient codes and is in PICU intubated.
What is communication errors?