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Successful Charting for Child Life Interns

Learning module designed to give tips to child life interns for successful charting.
by

Debbie Wagers

on 10 January 2015

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Transcript of Successful Charting for Child Life Interns

Why Chart?
Delineates role of child life specialist
Enhances professional status - increases visibility
Provides medical documentation to services received
Offers in-depth knowledge to staff about patient's developmental level psychosocial needs
Offers staff insight into
child's understanding of medical environment
SOAP
Subjective
Objective
Assessment
Plan
SUBJECTIVE
Statement of problem or concern
Subjective statements indicate what the note will be about
Subjective statements "hook" the reader
OBJECTIVE
"Just the facts, Ma'am"
Observed behaviors, statements & facts
Should back up your assessment
ASSESSMENT
Use knowledge of development & experience to formulate/state concerns - your professional opinion
Reflect information provided in objective section
A clear relationship between the assessment and objective data must be evidenced
Address therapeutic goals the CCLS will address
PLAN
State plan that CCLS will take to alleviate the concerns as listed in subjective section
Can include pager number for easy contact reference
May involve other multidisciplinary team members needed to meet goals
List of reference materials given - list by name
Outline specific actions necessary to meet therapeutic goals
APIE
Assessment
Planning
Intervention
Evaluation
ASSESSMENT
Appraisal of child/family based on developmental theory and psychosocial findings
PLAN
Statement of specific intended service
INTERVENTION
Provision of planned service
EVALUATION
Evaluate effectiveness of intervention
Narrative Note
Offers a narrative of events that occurred regarding CCLS interventions
Includes objective data
Written when an assessment not formally made
Summarizes events or concerns
Not extremely lengthy
Joint Commission requirement
Continuity of patient care
Multidisciplinary communication
Charting "Mechanics"
Entry always headed with title "Child Life Note"
All entries are dated and military time is used
Always done in black or blue
Handwritten Chart Notes
Errors are initialed and indicated
by a single line through error
Do not skip lines
Entered in Progress Notes
unless otherwise specified
If an entry ends midway through
a line, mark off remainder of line
Late entries should be
labeled and dated
Electronic Health Records
All entries are automatically dated and
military time used
Use only approved hospital abbreviations
Use only approved
hospital abbreviations
Chart on day of intervention
Regarding All
Chart Notes
Include signature and title
Certified Child Life Specialists use CCLS
Non-certified Child Life Specialists use BS or BA only (not BS, CLS)
Child Life Assistants use CLA
Interns use Child Life Intern (notes co-signed by Child Life Specialist)
Charts are legal documents; can be used in court.
Never make an entry or sign for someone else
Always use legal terms (mother and father, not mom
and dad)
Provide info regarding family members'
relationship to child (paternal grandmother, maternal aunt)
Should be free of judgments;
behaviors should be described
Sticker Note
Useful for quick charting
Check marks on sticker to help identify what CCLS provided or utilized for patient
Does not need
lengthy addendum
Supports need
for CCLS
Institutionally directed
Some have check
box mentality
Small narrative
section
Entries should never use words
or phrases which require clinical
diagnosis (i.e., hyperactive,
depressed, etc.) If family reports child
has clinical diagnosis, the entry must
cite the source of information.
Examples:
Concern for patient's development has been expressed
Received consult to address patient's behavior during PT treatments
Concern note by child life for patient's adjustment to hospital stay
Examples:
During play sessions, CLS observed pt playing with other children initiating contact and conversation, and making choices about play materials.
Provided mats and interactive toys as a means of promoting opportunities to develop reaching skills and head control.
Provided developmentally appropriate preparation for procedure utilizing photos, relevant medical equipment and teaching puppet. Pt engaged in preparation and rehearsed sequence of events as a means of gaining mastery and control.
Examples:
Plan to continue to see pt daily to provide developmentally appropriate play opportunities to promote normalcy, opportunities for choice and socialization.
Will gather educational literature for family regarding typical responses to trauma
Will communicate parent's concerns with the medical team.
Developmental Evaluation Tips
The hospital is one of the worst places to assess development.
Always ask parent about milestones child is successfully doing.
If you are asking parent about milestones which are likely beyond child's age, reassure parent you do not expect child is able to perform them.
Know what milestones are age-appropriate. If you don't know them, look them up.
Significant Items to Note:
History of age the pt acquired basic milestones (i.e., walking, sitting, word usage)
Note special services pt is receiving (OT, PT, Speech)
If child is in organized educational program (preschool 3 half-days, weekly, kindergarten)
If word usage is five-ten words, list the words
Use the approximate number of words rather than "a few" or "several."
Document quality or duration of skills (sits independently for 5 minutes, or walks dragging right foot)
Always remember to note medical equipment during assessment (Pt had IV and arm board during assessment which may have impacted observed skills.
Note amount of time you observed child (Pt has utilized playroom approximately 1 hour since admission.)
Charting OBJECTIVE data:
Document if parent reported specific skills or if you, as professional, observed them.
You can not diagnose developmental delays, this is not a medical diagnosis. Instead chart, "Concern noted for Sarah's development as she is not performing milestones typical of a child her age.
If child has developmental delay as diagnosed by physician, it is okay to refer to this.
Always try to document 4 7/12 year old.
If parent uses term to describe child, put the exact term used, "a little slow" or "age appropriate."
Remember:
If you have concerns about a child's development, always note it.
Remember, hospitalization causes regression, so always note this before a concern (It is always difficult to know if the developmental skills noted are typical of Anna or a result of regression during this hospital stay. However, per mother's report, Anna is not exhibiting skills typical of a 2 3/12 year old.)
Always document whom you shared your concerns with (Shared above observations with Laura Jones, case manager) or (Shared concerns about developmental skills with Dr. Witt.)
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