Question

Research types of charting, and discuss one that you feel is the best and why you chose it. Would it work in all areas of medicine and why? Provide one reference to support your discussion.

Answer 1

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Answer:

CHARTING AND ITS TYPES

Charting is the act of making a record of medical information of the client. The client can be accessed by the client and other members of health care team. The chart can be seen by other persons like a relative unless it is permitted by the client. Here are the following types of charting:

• Narrative charting

It is a descriptive account written chronologically in paragraphs that contains details of:

   - The client's condition

   - Interventions and treatments

   - The client's response to treatments

• Source-oriented charting

This is a narrative recording of each member of the health team using separate sheets.

• Problem-oriented charting

This is a logical method of documentation composed of:

- Database

   - Problem list

   - Plan of care

   - Progress notes

The progress notes can be written using the SOAP, SOAPIE, or SOAPIER method.

1.    Subjective data - these are what the client or significant others report, believe, or feel.
2.    Objective data - these are what can be observed or obtained from other sources, such as diagnostic and laboratory studies, old medical records, our other health care providers.
3.    Analysis of data – this is the identification of the client's needs of problems.
4.    Plan - this includes setting priorities, establishing goals, identifying desired client outcomes, and determining specific client nursing interventions.
5.    Intervention - the plan of care is put into action.
6.    Evaluation - determining the client's toward attaining the identified outcomes.
7.    Revision - the need to revise interventions.

• PIE Charting

A direct form of charting composed of:

1. Flow sheets

2. Progress notes

3. Plan of care

The plan of care takes into account the following:

1. Problem

2. Intervention

3. Evaluation

• Focus charting

Utilizes a column format for:

1. Data (subjective/objective)

2. Action (intervention)

3. Response of the client

• Charting by exception

This is a narrative form of charting in which only the significant findings are documentation.

• Computerized charting

It utilizes nursing information system that facilitates documentation through the use of computers. Examples of which are voice-activated terminals and bedside computer terminals.

• Point-of-care Charting

A portable bedside computer facilitates immediate input and retrieval of client data

KEEP GOOD NURSING RECORDS

The patient's record must provide an accurate, current, objective, comprehensive, but concise, account of his/her stay in hospital. Traditionally, nursing records are hand-written. Do not assume that electronic record keeping is necessary.

• Use a standardised form. This will help to ensure consistency and improve the quality of the written record. There should be a systematic approach to providing nursing care (the nursing process) and this should be documented consistently. The nursing record should include assessment, planning, implementation, and evaluation of care.

• Ensure the record begins with an identification sheet. This contains the patient's personal data: name, age, address, next of kin, carer, and so on. All continuation sheets must show the full name of the patient.

• Ensure a supply of continuation sheets is available.

• Date and sign each entry, giving your full name. Give the time, using the 24-hour clock system. For example, write 14:00 instead of 2 pm.

• Write in dark ink (preferably black ink), never in pencil, and keep records out of direct sunlight. This will help to ensure they do not fade and cannot be erased.

• On admission, record the patient's visual acuity, blood pressure, pulse, temperature, and respiration, as well as the results of any tests.

• State the diagnosis clearly, as well as any other problem the patient is currently experiencing.

• Record all medication given to the patient and sign the prescription sheet.

• Record all relevant observations in the patient's nursing record, as well as on any charts, e.g., blood pressure charts or intraocular pressure phasing charts. File the charts in the medical notes when the patient is discharged.

• Ensure that the consent form for surgery, signed clearly by the patient, is included in the patient's records.

• Include a nursing checklist to ensure the patient is prepared for any scheduled surgery.

• Note all plans made for the patient's discharge, e.g., whether the patient or carer is competent at instilling the prescribed eye drops and whether they understand details of follow-up appointments.

Writing tips

• Ensure the statements are factual and recorded in consecutive order, as they happen. Only record what you, as the nurse, see, hear, or do.

• Do not use jargon, meaningless phrases, or personal opinions (e.g., “the patient's vision appears blurred” or “the patient's vision appears to be improving”). If you want to make a comment about changes in the patient's vision, check the visual acuity and record it.

• Do not use an abbreviation unless you are sure that it is commonly understood and in general use. For example, BP and VA are in general use and would be safe to use on records when commenting on blood pressure and visual acuity, respectively.

• Do not speculate, make offensive statements, or use humour about the patient. Patients have the right to see their records!

• If you make an error, cross it out with one clear line through it, and sign. Do not use sticky labels or correction fluid.

• Write legibly and in clear, short sentences.

• Remember, some information you have been given by the patient may be confidential. Think carefully and decide whether it is necessary to record it in writing where anyone may be able to read it; all members of the eye care team, and also the patient and relatives, have a right to access nursing records.

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BEST CHARTING METHOD

FDAR CHARTING . FDAR stands for Focus (F), Data (D), Action (A), and Response (R ).

It is a handy way to chart and save time. In this article, I was to simplify FDAR charting for you and show you the following:

• What F-DAR charting is and why it is used
• What F-DAR charting looks like
• Explain each section of the F-DAR and what it includes
• Give Various Examples for different charting scenarios

What is F-DAR charting and why it is used?

It is a method of charting nurses use, along with other disciplines, to help focus on a specific patient problem, concern, or event. It is geared to save time and decrease duplicate charting. It is a great charting method for nurses who have a lot of patients and is easier read by other professionals. It gives other professionals a snapshot of what went on during your shift in a concise manner.

It is used not only by nurses but other disciplines like nutritionists, occupational therapy, case management etc. Most health care settings are requiring disciplines to now document in the F-Dar format.

Below is an example of what a typical FDAR charting set-up looks like. Note how it is split into columns (the date/time, focus, and progress note which are all in separate columns)

What does the FDAR stand for?

F (Focus): This is the subject/purpose for the note. The focus can be:

• Nursing diagnosis
• Event (admission, transfer, discharge teaching etc.)
• Patient Event or Concern (code blue, vomiting, coughing)

D (Data): This is written in the narrative and contains only subjective (what they patient says and things that are not measurable) & objective data (what you assess/findings, vital signs and things that are measurable). This lays the supporting evidence for why you are writing the note. You are letting the reader know “this is what the patient is saying and what I’m seeing”.

A (Action): This is the “verb” area. In this section, you are going to write here what you did about the findings you found in the data part of the note. This includes your nursing interventions (calling the doctor, repositioning, administering pain medication etc.)

R (Response): This is where you write how the patient responded to your action. Sometimes, you won’t chart the response for several minutes or hours later.

IT CAN BE USED IN ALL MEDIACL AREAS BECAUSE:

The principal advantage of focus charting is in the holistic emphasis on the patient and his/her priorities including ease in charting.