Changes in electronic health records leave considerable flexibility for medical care providers to document patient care. Several electronic charts have many options to capture patient care, but others have few options. Also, being unable to capture sufficient patient care necessary to demonstrate that both criteria are met,
An example of a document that is frequently seen in medical records and is often presented as a problem in a court is related to the collapse of the skin. Basically, patients who can not adjust their position need to prevent skin collapse every two hours. According to the State Pressure Advisory Committee, many factors are taken into account in assessing tissue damage, but primary and primary intervention in all patients regardless of "other factors" is. In case of suspected tissue injury (bedridden), stage II, stage III, stage IV, or deep tissue damage, scrutiny of care should be taken into consideration for the prevention of wounds if the patient is at least as close as possible to the standard Care
Nursing negligence may be accused of not going around the patient every two hours. In addition, it is assumed that a falling patient was not taken if the medical record does not indicate that the care plan of care includes an actual or potential problem addressing a change in skin integrity. If an injury occurs, there is a possibility that a correlation may be established between the nurse and the nurse. I could not turn the patient, which led to destruction of the skin.
According to the medical records, it is considered that "other physical factors" contribute significantly when the patient rotates every 2 hours and it turns out that an advanced wound is still occurring. In the absence of other physical factors, the document may be regarded as an invalid chart. Other physical factors include, but are not limited to, test results, diabetes, coronary artery disease, previous surgery, age, infection and so on.
Examples of cases in which care was not documented and the care of additional care was done are as follows.
• The head of the bed is lifted. The elevation recorded to a special extent is important when care is accompanied by aura of aspiration and limits fluoroscopy or hemodynamic measurements.
• Response to drug titration in critical treatment areas. Titration of medication is expected to occur until the desired effect is achieved, especially when the order is written in protocol format. The medication management recorded in the medical records should reflect the appropriate clinical judgment by the nurse.
• Intervention for fall prevention. Simply recording or checking is not enough. If the patient collapses with your shift, does the record show that what was stated in the protocol was done to prevent fall? Specifically describe the interventions used when caring for patients judged to be at higher risk of injury.
The medical record entry must be fact, accurate, complete and timely. We will use FACT rules. It is very easy to remember.
FACTUAL means that the details of the fact that the story describing the patient's care is clear enough. The fact is clinical findings that the nurse knows the truth. Facts are test results, clinical assessment, medication, vital signs, which may mean what patients say. Please put what the patient says in "quote". Beginner's knowledge is another way of deciding what should be charted. The best practice is to chart only what is known to be true. The exception to this practice is the crisis intervention when the situation uses scribes during code or prompt response. The scribe chart is created as the event is deployed, and after the patient is stabilized by the medical team, the accuracy of the document is confirmed.
ACCURATE means that facts must be recorded correctly. The lab needs to enter accurately unless it passes through the electronic health record portal system. Moving only one decimal point when recording the dosage administered will tell you that the dosage will increase by 10 or 100 times the dosage. Imagine that the record that the nurse administered 10 mg of atropine instead of 1 mg was reflected. If the fatal result appears to be related to medication errors, how is this error protected?
Complete medical record entry is a thorough entry. Please do not guess the patient's care and leave it to the reader. Please use "OPQRST" to check the entries of the chart.
"O" is for sunset.
"P" is for predicting or exacerbating factors.
"Q" is quality or quantity
"R" is for radiation
"S" is for the situation
"T" is time (time)
The last word is timely. Entries for medical records are expected to be written at the same time. Every means means to create a chart as soon as possible after the event has occurred. Timely high skill setting is not the same timely in low level care, including long term care settings. The higher the sharpness, the more entries are expected to be recorded for patient care. A lower level of sharpness results in fewer orders, fewer interventions, fewer interactions, fewer entries representing rendered care. The frequency of participation needs to be adjusted according to the facility's policy and the level of patient acuity.
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