Question

Why is it important for you to properly chart a patient's findings? What can happen if you do not chart these findings correctly? What advise do you have for classmates on how to improve their learning of proper charting techniques?

Answer 1

Why it's important to chart your findings in chart

the purpose of a medical chart is to serve as both a medical and legal record of an individual's clinical status, care, history, and caregiver involvement. The specific information contained in the chart is intended to provide a record of a person's clinical condition by detailing diagnoses, treatments, tests and responses to treatment, as well as any other factors that may affect the person's health or clinical state

Being a healthcare staff who is spending most of the time with the patient, the nurse knows a patient better than the clinician. He or she may be the one who finds a pressure sore, changing rythm of pulse, discharge from a surgical site, febrile episodes in an operated patient etc. These observations change the entire course of the treatment. These are signs which is picked up early can avoid great disasters. That is why it become important two documents promptly the findings in the chart. If all healthcare staff does the same there won't be any missing pieces of information. Legally also it's the responsibility of the assigned staff to document Atmost care the findings regarding a particular patient without fail

2. What if the staff is not charging the findings correctly?

If the stuff fail to documents findings promptly it might put the life of the patient in danger. Say for example is single documentation of low BP could be a sign of cardiovascular which if documented promptly might save the life of the patient. Charting the findings is it legal liability off the healthcare staff. If she fails to do that promptly there could be disciplinary actions. This is because it is a crucial document in the hospital stay if reach patient that decide the course of the patient in the hospital.Nurses have a tremendous responsibility to accurately complete patient charting, which is vital in preventing medical errors, delivering high-quality patient care and protecting medical staff from liability and malpractice claims .

1. Find balance
Nurses are taught to live by the credo ‘If it wasn’t charted, it wasn’t done, that said, nurses must balance the requirement of charting care provided with actual face-to-face time with the patients. In the age of the electronic medical record (EMR), nurses who are able to integrate technology at the bedside will find an efficient flow to documentation and patient interaction.

2. Use technology to the fullest
Burger emphasizes the importance of nurses learning to use the EMR to their advantage when completing their nursing chart. “Many EMRs are designed to list body systems in a specific order, with a ‘Within Normal Limits’ as the default. That shouldn't be allowed.

3. Avoid double-documenting

nurses have a difficult time with the design and functionality of the EMR, most information is contained in flowsheets and data sets. Nurses should refrain from wasting time double-documenting in a narrative and the flowsheets. Nurses should use a narrative note only when needing to tell the story of a patient event or when there is a designated shift summary link for the care team.

4. Document in real time
Nurses should strive to document in real time as opposed to batching their have shown thdocumentation. it takes longer to batch-chart than it takes to document the care at the point of service. Another important reason to document in real time is the ability of many EMRs to use predictability models in the programming that actually alert the nurse, or rapid response team, that the patient is declining or expected to decline.

5. Avoid pre-charting
The busier you are, the harder it is to keep your nursing charts updated, which is when errors and omissions are more likely to occur, reports the Denver College of Nursing. This is also when it’s most crucial to carefully document your actions. However, never chart in advance. Wait until tasks are completed to avoid potentially serious repercussions.

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