PATIENT CARE MANUAL POLICY
NUMBER #V-20
DATE
PAGE
July 5, 2010
1
APPROVED BY:
Senior Vice President of Medicine & Chief of Staff, and
Vice President & Senior Operating Officer; Rural Health
Services & Professional Practice Lead
CATEGORY:
Documentation
TITLE:
Patient Chart Documentation
Purpose
Policy
Statement
Applicability
OF
2
To provide guidelines to ensure that health care providers record
information in a manner that is consistent with organizational and
unit/department charting standards.
Covenant Health staff and physicians shall maintain an accurate and
complete health care record of each patient and will adhere to
organizational and unit/department charting standards.
This policy applies to Covenant Health – Edmonton Acute care facilities.
Responsibility Covenant Health staff and physicians who provide care shall document on
the patient care record and will demonstrate compliance with organizational
and unit/department charting standards.
Principles
Documentation in the health care record provides a:
1.
2.
3.
4.
5.
6.
7.
legal record of the patient’s assessment and treatment
communication tool for health care providers
method to identify problems and organize the treatment plan
tool for evaluating the efficacy of treatment
basis for peer review or quality assurance review
basis to ensure continuity of care
record for research projects that a patient may be part of.
NUMBER #V-20
DATE
PAGE
TITLE:
Related
Documents
July 5, 2010
2
OF
Patient Chart Documentation
Patient Care Manual P/P #V-35. Preprinted Patient Care Orders
Patient Care Manual P/P #III-115, Medication Orders
Patient Care Manual P/P #V-5, Completion of Health Records by
Medical Staff
Patient Care Manual P/P #V-15, Patient Care Record
Accompanying the In-patient for Tests/Treatments
Instructions for Use of the Nursing Assessment and Care Record
2
APPENDIX A
NUMBER V-20
DATE July 5, 2010
PAGE
TITLE:
1
OF
2
Patient Chart Documentation
GUIDELINES FOR ‘CHARTING’
1.
2.
3.
Record only what you saw, heard or did.
•
Only document your own actions or observations. If circumstances arise that
you must document the care given by others, the record should clearly
identify both the caregiver and the individual who is documenting the
information.
•
Do not include opinions or judgements.
Record in a concise, factual and clear manner.
•
Use objective descriptors (do not use words like ‘good’ or ‘fine’).
•
Ensure your notes are legible and that your signature is immediately
identifiable (and/or identifiable using the signature log as appropriate for the
specific unit/department).
•
The use of abbreviations is discouraged and staff shall not use abbreviations
listed in the “Prohibited Abbreviations” or “Dangerous Abbreviations” lists per
Patient Care Policy/Procedure #III-115, Medication Orders.
•
Record in black ink on forms approved by the department.
•
Ensure the correct patient and hospital identification is on the upper right
hand corner of each page of the patient’s record.
Record consistently with unit/department guidelines and charting
methodology.
APPENDIX A
NUMBER V-20
DATE July 5, 2010
PAGE
TITLE:
2
OF
2
Guidelines for Charting
GUIDELINES FOR ‘CHARTING’ - continued
4.
Record contemporaneously* and in chronological order.
(*definition: the ability to chart as soon as able)
The ability to chart as soon as able and the amount of charting detail are dictated
by a number of factors, including:
a)
b)
c)
d)
•
5.
organizational/unit policies and procedures, guidelines, practice
NOTE: depending on the nature of the work, individual
departments or areas may have specific charting requirements.
When a department-specific charting standard varies from this
policy/procedure, the standard of greater expectation will prevail.
the complexity of the health problems
the degree to which the patient’s condition puts him/her at risk; and
the degree of risk involved in the treatment or care.
It is imperative to record an event at the time it occurred (or as close as is
prudently possible). The rationale for this is the notation is more likely to be
viewed as accurate if it is made close to the time of the event. And, when an
entry must be added out of order (late entries are better than no entries), the
entry should be dated and signed, indicating both the time of entry and the
time the event itself occurred.
Record corrections clearly.
•
Correct errors but don’t obliterate them. Never erase or apply correction fluid.
Make a straight line through the mistake so that it remains legible and write
your initials beside it.
•
The new entry should include the date, time at which the correction was
made, and the writer’s signature.
APPENDIX B
NUMBER V-20
DATE July 5, 2010
PAGE
TITLE:
1
OF
Patient Chart Documentation
GUIDELINES FOR ‘CHARTING BY EXCEPTION’
DEFINITIONS
Charting by Exception
¾ A method of documenting patient assessment parameters/critical indicators based
on clearly defined guidelines for practice; i.e. predetermined criteria for nursing
assessments, a plan of care, and expected patient outcomes.
Relevant Care
¾ Pertinent information that is documented regarding the patient. This should include
a change in patient condition or treatment/interventions, patient outcomes or
description of concerns.
1.
Covenant Health utilizes Charting by Exception in defined practice areas.
Practice areas using Charting by Exception must adhere to the aforementioned
“Guidelines for Charting”.
2.
When combined with predetermined guidelines of practice, symbol charting for
routine care and documentation of relevant care (eg. narrative charting and flow
charting), exception charting:
•
•
•
•
fosters analytical/critical thinking by the caregiver
facilitates conciseness, continuity of care, and tracking of information
promotes easy access to patient information, and
decreases duplication.
3.
The major activities reflected in any documentation process (eg. admission data
base, care plans, protocols, flow sheets, progress notes) are included in
exception charting. Documentation is by reference to predetermined guidelines
for practice and relevant care; however, some aspects of narrative charting and
flow charting will still be found in the patient record.
4.
Patient care areas that utilize the exception charting method (eg. CareMaps or
assessment tools) shall have guidelines describing how to document on the
patient care record1 which must be adhered to.
5.
Narrative notes could include assessment, intervention, and patient response.
Record when there is a significant change in the patient’s status or treatment.
NOTE: In some practice areas the charting guidelines indicate progress and
narrative notes are not necessarily done if the significant change is toward the
norms.
1 Burke & Murphy. Nursing ’90. May 1990.
1