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Sarah Lack

on 6 May 2014

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Transcript of Documentation

17 Tips &
Case Studies
Date and Time?
Assessment Data?
Pain level and quality of pain?
Subjective Data?
Reassessment? LOC?
Sedation Scale?
Any patient Education?
Basic Steps for
Good Documentation
1. Be accurate
2. Chart objective information
3. Chart as soon as possible after care is given
4. Write legibly
5. Use only approved abbreviations
"If it isn't charted
It isn't done"
Standard of care includes the principle that any of your coworkers should be able to pick up a chart and understand the status of that patient’s condition and care.
Financial reimbursement - Third party payers evaluate the documentation in a patient record to determine whether payment is appropriate.
A patient record may form the basis for the filing of a lawsuit against medical malpractice - An accurate medical record is the nurse’s best defense
Potential disciplinary action by the Board of Nursing against your license, as the result of inadequate or falsified documentation
Watch the RN - Patient interaction and document as if you were the RN providing care
for the record
Failure to report patient's deteriorating condition to the attending physician and administration of anxiolytic medication in the presence of respiratory distress
Post C-Section, possibility of uterine atony
medications to enhance uterine contraction
monitoring of vital signs
observations for signs of bleeding
monitoring of oxygen saturation levels
notify physician for any O2 sat below 95%
Improper insertion of intravenous access; Failure to properly administer IV Mitomycin...
IV was inserted without difficulty
A later check by the RN found the catheter had dislodged from the vein.
There was no evidence that the Mitomycin had extravasated
The RN stopped the IV
Notified the physician
Provided care to the patient's hand
Frequent Flyer
Intoxicated Agitated Aggressive
Placed in four point restraints and contraband check by security staff per hospital protocol
15 minute checks with monitoring and assessment findings at each check were fully documented in the patients health record, including 1 missed check with the explanation of why the check was missed
Patient attempted to burn off his restraints with a cigarette lighter, igniting his bed linens and clothing resulting in sever burns over 25% of his body
Full transcript