Changes in electronic health records provide considerable freedom for healthcare providers to document patient care. Some electronic health records offer many options to capture patient care, while others offer very few options, and both know that they have not received enough patient care to demonstrate that standard care has been achieved.
Examples of documents that are common in medical records often appear as problems in court, related to skin breakdown. Fundamentally, preventing skin from rupturing requires turning the patient who cannot adjust the position every two hours. According to the National Stress Advisory Group, many factors are considered when assessing tissue damage, but the first and major interventions for all patients are converted to patients. When tissue damage develops [acne], stage 2, stage 3, stage 4 or suspected deep tissue damage, a detailed review of care will include providing care to the patient at least even up to standard wound prevention.
Negligence may be caused by failure to rotate the patient every two hours. In addition, if the medical record does not indicate that the care plan includes an actual or potential problem that addresses a change in skin integrity, then the referral patient is assumed to be incomplete. If the casualty develops, a correlation may be established between the nurses. Failure to rotate the patient causes the skin to rupture and cause the skin to rupture.
"Other physical factors" are considered a significant contribution when the medical record clearly indicates that the patient has switched every two hours and still develops a stunted wound. If there are no other physical factors, the document may be considered a fake chart. Other physical factors include, but are not limited to, laboratory results, diabetes, coronary artery disease, previous surgery, age, infection, etc.
Examples of not documenting care and causing additional care reviews are as follows:
• The bed is raised. It is important to record a certain degree of height when care involves aspiration prediction, restriction or hemodynamic measurements.
• Response to drug titration in intensive care areas. It is expected that the titration of the drug will occur until the desired effect is achieved, especially when the order is written in a protocol format. Drug management recorded in the medical record must reflect the appropriate clinical judgment of the nurse.
• Anti-fall measures. Just recording or checking is not enough: the fall protection agreement is in place. If the patient falls, does the record show what is listed in the agreement to prevent a fall? Specify the interventions used when caring for patients identified as having a higher risk of injury.
Medical record entries must be factual, accurate, complete and timely. Use FACT rules. This is easy to remember.
FACTUAL means that there must be enough factual details to describe the story of patient care is clear. The truth is the true clinical findings that nurses know. The facts may be laboratory results, clinical assessments, medications, vital signs, or what the patient said. Tell the patient in the "citation". First-hand knowledge is another way to determine which chart should be drawn. The best practice is to draw only charts that are known to be true. An exception to this approach is that during crisis interventions, when the situation uses scribes, it may be done during code or quick response. After the medical team stabilizes the patient, the document will be checked for accuracy as the event unfolds.
Accuracy means that facts must be recorded correctly. If the laboratory does not cross the electronic health record portal system, it must be entered into the laboratory accurately. When the administered drug is recorded, moving the decimal point by only one position may indicate that the administered dose is 10 times or even 100 times the dose ordered. Imagine if the record reflects that the nurse gave 10 mg of atropine instead of 1 mg. If a catastrophic result seems to be related to a medication error, how will this error be protected?
A complete medical record entry is a multitude of entries. Don't let the reader guess the patient care provided. Use "OPQRST" to check the completion of the medical record.
"O" indicates the offset.
"P" is used to predict or aggravate factors.
"Q" stands for quality or quantity
"R" for radiation
"S" stands for the situation
"T" stands for time [time of day]
The last semester, TIMELY. It is expected that medical record entries will be written at the same time. All of this means drawing the chart as soon as possible after the event. In the higher level of care [including long-term care settings], the timely setting of high acuity is the same as in time. The higher the acuity; more entries on patient care are expected to be recorded. A lower acuity will have fewer orders, less intervention, less interaction, which is equivalent to fewer entries indicating the care provided. The frequency of entries should be adjusted according to facility policies and patient acumen.
Orignal From: Charts to draw when you can't draw all the charts: Practical tips for nursing documents
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