PURPOSE To provide the multidisciplinary team with a structured note format for documenting • The patient’s health and well being • The care provided • The effect of the care and the continuity of the care.
Focus charting brings the focus of care back to the patient and patient concerns.
Documentation Will reflect : • Collection and analysis of Data • Actions taken • Evaluation of outcomes by supporting critical thinking by the Health Care Professional in the clinical decision making process.
Documentation Forms • Chart Documentation Signature Sheet NB 192 • Clinical Record NB 162 300 McLaren • Appropriate NBGH Flowsheets • Dictaphone/Tape Record
Procedure • Ensure the imprint of the addressograph on the Clinical Record corresponds to the correct patient. • Document on appropriate forms approved by the North Bay General Hospital. • Document the date and time of the care, or the event, in the designated columns on the Clinical Record.
Procedure • Black permanent ink is to be used when charting • Each Health Care Professional who documents in writing in the patient’s record must sign and initial on the Chart Documentation Signature Sheet • All documentation will be accompanied by appropriate identification of the caregiver making the entry onto the patient chart.
Documentation Principles Documentation must be able to determine: • When an event happened • What happened • To whom it happened • By whom it happened • Why it happened • The result of what happened
Documentation Principles • Maintain confidentiality of all patient information. • Documentation will be retrievable • Documentation is to be neat, legible, and non-erasable. • Records must be an accurate, true and honest account of what occurred and when it occurred.
Documentation Principles • Documentation contains meaningful information, and avoids meaningless phrases, such as, “good night,” “up and about,” or “usual day. Information documented must be relevant . • Provides current, clear, complete, concise, concrete, documentation of the patient’s status with the least possible duplication of information.
Documentation Principles • Documentation must be reflective of observations not unfounded conclusions. • Avoid statements such as, “appears to” and “seems to” when describing observations. • Documentation must reflect the assessment, planning, implementation and evaluation of patient care.
Documentation Principles • Documentation will contain all clinical observations, actions taken by the health care providers, all treatments, as well as, the patient’s response to the care provided.
Documentation Principles • Document in a timely manner, during or as soon as possible, after the delivery of care. Never chart before the delivery of care. • Chart in chronological order, documenting entries in sequence of events. Do not document in blocks of time i.e. August 16, 2006 1200 – 1600 hours
Forgotten or Late Entries • Forgotten or late entries are to be documented on the next available space within the Clinical Record.
Forgotten or Late Entries • Documentation must clearly state when the care was provided or when an event occurred, and when the documentation of the care/event occurred to be reliable. Regardless of how late the entry, the information documented must be accurate and complete. Late entries should be clearly marked as a late entry i.e. documenting the date and time of the entry, and the date and time that the care was given or when the event took place.
Corrections • Corrections are made in a timely, honest and forthright manner. • Place brackets at the beginning and end of the error and then neatly drawing a single line through the error and document “error” and initial above the incorrect entry. • The original information must remain visible or retrievable in the health record. • Document the new entry including the date, time and your signature and status
Documentation Principles • Do not delete or alter an entry made by another Health Care Professional. • Do not use ‘whiteout’, erasers, highlighter or entries between lines. • Do not leave blank lines between entries. If a blank line is inadvertently left, draw a line through the space so that no further entry can be documented.
Documentation Principles • When documentation of an entry continues from one page to the next, the bottom of the first page is to be signed off. Enter the date and time in the appropriate column on the next page and document in the Clinical Notes “ cont’d.”
Abbreviations • Use abbreviations according to policy ADM 1 – 30 Abbreviations / Signs / Symbols – Accepted • Note: We do not have any approved symbols.
Documenting for Others • The person who saw the event, or performed the action, documents in the record, except in situations such as, a cardiac arrest, when one Health Care Professional will be designated as recorder and will document the care provided by another Health Care Professionals.
Documenting for Others • In the event another Health Care Professional assists you in the care of your patient, it is acceptable for you to document the action and patients responses, noting the name of the other care provider that assisted, for example, in a critical incident such as a fall, or a telemetry report you received from a Critical Care Unit staff member.
Documenting for Others • Interventions initiated by another Health Care Professional, on your assigned patient such as, initiation of an IV will be documented by the Health Care Professional performing the intervention
Structured Narrative Note Format DAE
NARRATIVE NOTE FORMAT • There are four elements in Focus Charting: 1.) The Focus Column identifies the content or purpose of the narrative entry and is separated from the body of the notes in order to promote easy data retrieval and communication.
Focus • Narrative documentation on the Clinical Record begins with Focus identification. • The Focus is documented utilizing akey word or phrase that communicates to the Multidisciplinary Team what is happening with the patient, or to identify a significant event in the course of therapy.
FOCUS • Focus charting is patient-centered rather than problem oriented and addresses the patient’s strengths, concerns. • Documentation describes the patient’s perspective and focuses on documenting the patient’s current status, progress toward goals/outcomes, and responses to interventions.
FOCUS • Includes present positive occurrences not just negative problems or needs. • Based on patient concerns, diagnosis, behaviors, treatment/therapy and or response.
FOCUS • A focus will identify a change in a patient’s condition or behavior, such as disorientation to time, place and person. • A significant event in the patient’s treatment/therapy, such as, safety concerns, or initiation of Blood Transfusion
FOCUS • An acute change in condition such as fluid overload, or seizure etc. • Monitoring and assisting in problems related to physiologic functions of hydration, nutrition, respiration, elimination.
Focus • Patient teaching or counselling • Consulting with physicians or other disciplines in collaborative or multidisciplinary care.
Focus • Findings such as; safety concerns, physician visit, monitoring, ADL’s, or functional health patterns, determined during the admission assessment and ongoing assessments. • A current patient concern or behavior, such as pain, swallowing, feeding, dressing. • A sign or symptom, such as, an abnormal Vital Sign.
Foci using Flow Sheet NB 114 • Activity • Hygiene • Nutrition • Elimination • Oxygenation • Safety Concerns/Injury • IV Therapy / Medication • Cast • CMS • Dressing • Drainage Systems
Focus • Incontinence • Infection • Isolation • Mental / Emotional Status • Nausea / Vomiting • Neurovascular • Musculoskeletal • Pain Control • Physician/Visit/Assist/Notified • Physical Status • Respiratory Status • Restraints • Skin Integrity / Wound Care • Spiritual Interventions • Swallowing • Substance Abuse • Teaching • Telemetry • Transfer • Vital Signs • Wound Care
DAE • Documentation of DAE will follow the Focus entry. The notes will be structured using the following categories.
D Data • A Action • E Evaluation • These categories are meant as a guide to assist the caregiver in documenting all relevant data in a structured format. All entries will begin with a Focus. Components of “DAE” can be charted alone or out of sequence.
Data: Document by writing a “D:” on the Clinical Record followed by your findings related to the stated focus.
Data is, but not limited to: • Subjective and /or objective information that supports the stated focus or describes the patient status at the time of a significant event or intervention.
Data: • Subjective Data is information a patient tells the caregiver. Record patient statements, documenting exact quotes or paraphrased conversation. • Information can come from patient, family, or from other Multidisciplinary Team Members.
Data: • Objective data includes all relevant information obtained from sources other than verbal expressions. • Objective data can be measured, seen, heard, touched, or smelled
Action: Document by writing an “A:” on the Clinical Record followed by completed or planned interventions based on the caregiver’s assessment of the patient’s status.
Actions are, but not limited to: • Actions taken in response to the stated focus. • Concrete actions performed that assist the patient in reaching expected outcomes. • Medical treatments as ordered by physicians.
Actions • Treatments or interventions such as, teaching protocols, initiated and provided by Health Care Professionals. • Future actions or plans that have been initiated
NOTE: “ACTIONS” may be added to modify the intervention so progress is made toward the expected outcome