Escolar Documentos
Profissional Documentos
Cultura Documentos
Bashir/CoHS/UoH
28/01/16
Purposes
Communication
Planning client care
Quality management/auditing
Research
Education
Legal purpose
Bashir/CoHS/UoH
28/01/16
Bashir/CoHS/UoH
28/01/16
Reasons for
Documentation
Facilitate Communication
Promote good nursing care
Meet professional and legal
standards
Bashir/CoHS/UoH
28/01/16
Bashir/CoHS/UoH
28/01/16
28/01/16
ABCs of Charting
A- Accurate
B- Brief
C-Complete
Bashir/CoHS/UoH
28/01/16
GENERAL
GUIDELINES
IN
CHARTING
Bashir/CoHS/UoH
28/01/16
General Guidelines
Date & Time
8:00 am
8:00 pm
Military time avoids confusion
0800H
2000H
Bashir/CoHS/UoH
28/01/16
10
Guidelines in charting
Sign all entries
Bashir/CoHS/UoH
28/01/16
11
Guidelines in charting
Document from first
hand knowledge
Bashir/CoHS/UoH
28/01/16
12
General Guidelines
Timing
Document after care
Not before or after a lapse of
how many hours
Bashir/CoHS/UoH
28/01/16
13
Legibility
Bashir/CoHS/UoH
28/01/16
14
Permanence
Dark ink and permanent ink
Bashir/CoHS/UoH
28/01/16
15
Accepted terminology
Bashir/CoHS/UoH
28/01/16
16
Correct spelling
Bashir/CoHS/UoH
28/01/16
17
Signature
Amal Awad, BSN
J. Thomas, RN
9.3.29
9.3.29
Bashir/CoHS/UoH
28/01/16
18
Accuracy
patient refused medications
accurate
patient is uncooperative
Vague
Bashir/CoHS/UoH
28/01/16
19
Bashir/CoHS/UoH
28/01/16
20
Hassan Adnan,
R.N,BSN
28/01/16
Bashir/CoHS/UoH
21
Sequence/
Organization
Bashir/CoHS/UoH
28/01/16
22
Appropriateness
IRRELEVANT
Watcher entertaining male visitors
during visiting hours are
over and leaving the patient
most of the time.
Bashir/CoHS/UoH
28/01/16
23
Completeness
Bashir/CoHS/UoH
28/01/16
24
Legal
prudence
Bashir/CoHS/UoH
28/01/16
25
What
When
Where
Who
Why
How
Bashir/CoHS/UoH
28/01/16
26
Entry No. 1
6/6/00 0900 IV heplock started in left
hand...........RNavuluri, RN
Entry No. 2
6/6/00 0900 IV heplock started in left
hand using 20 G cathlon, and start kit per
telemetry protocol................RNavuluri,
RN
Bashir/CoHS/UoH
28/01/16
27
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28/01/16
28
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28/01/16
29
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28/01/16
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28/01/16
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