What is block charting in nursing?
Block charting is defined as a documentation method that can be used when rapid titration of medication is necessary in specific urgent/emergent situations defined in an organization’s policy. A single “block” charting episode does not extend beyond a four-hour time frame.
What are the types of nursing documentation?
The most common types of nursing documentation include the following:
- Nursing Progress Notes.
- Narrative Nursing Notes.
- Problem-Oriented Nursing Notes.
- Charting By Exception Nursing Notes.
- Nursing Admission Assessment.
- Nursing Care Plans.
- Graphic Sheets.
- Medication Administration Records (MARs)
What should nursing documentation include?
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.
What are the documentation standards?
Documentation process standards define the process used to produce documents (example here). This means that you set out the procedures involved in document development and the software tools used for document production. Document process quality standards must be flexible and able to cope with all types of documents.
How do you document medication refusal?
DOCUMENTING INFORMED REFUSAL
- describe the intervention offered;
- identify the reasons the intervention was offered;
- identify the potential benefits and risks of the intervention;
- note that the patient has been told of the risks — including possible jeopardy to life or health — in not accepting the intervention;
What are the general guidelines for nursing documentation?
In addition, general guidelines to follow include: Always assess the patient at the time of discharge or transfer. It’s vital to know the status of a patient before he leaves or enters your care. Always use a chronologic documentation format, providing separate entries for each narrative item.
What happens if your nursing documentation is incomplete?
No matter how skilled or experienced you are, inaccurate or incomplete nursing documentation can mean serious trouble for your patients—and for you if you’re ever involved in a lawsuit. This article provides practical guidelines to help you document your assessments and interventions completely, accurately, and concisely.
Do you use medical terminology in block charting?
Block charting, or charting that doesn’t separate each activity by timed entry, doesn’t provide a clear picture of the sequence of events surrounding the care of the patient. Never use medical terminology unless the meaning of the word is known. When in doubt, spell it out.
What makes a legal document in nursing care?
Therefore, documentation is the creation of a legal document reflecting optimal patient care given in accordance with appropriate standards of care.