Charting: An Incredibly Easy! Pocket Guide

416 Pages·2006·4.55 MB·English

by  Springhouse

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Charting
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5389 FM.qxp 3/15/12 11:00 AM Page ii
Co
Staff The clinical treatments described and recom-
mended in this publication are based on re-
Executive Publisher search and consultation with nursing, medical,
Judith A. Schilling McCann, RN, MSN and legal authorities. To the best of our knowl-
edge, these procedures reflect currently accept-
Editorial Director ed practice. Nevertheless, they can’t be consid-
David Moreau ered absolute and universal recommendations.
Clinical Director For individual applications, all recommendations
Joan M. Robinson, RN, MSN must be considered in light of the patient’s clini-
cal condition and, before administration of new
Art Director or infrequently used drugs, in light of the latest
Mary Ludwicki package-insert information. The authors and
Senior Managing Editor publisher disclaim any responsibility for any ad-
Jaime Stockslager Buss, ELS verse effects resulting from the suggested pro-
cedures, from any undetected errors, or from the
Clinical Manager reader’s misunderstanding of the text.
Collette Bishop Hendler, RN, BS, CCRN
Clinical Project Manager © 2007 by Lippincott Williams & Wilkins. All
Cynthia Brophy, RN, BSN, CPAN rights reserved. This book is protected by copy-
right. No part of it may be reproduced, stored in a
Editors retrieval system, or transmitted, in any form or by
Liz Schaeffer, Gale Thompson, any means—electronic, mechanical, photocopy,
BethWegerbauer recording, or otherwise—without prior written
Clinical Editor permission of the publisher, except for brief quo-
tations embodied in critical articles and reviews
Marcy Caplin, RN, MSN and testing and evaluation materials provided by
Copy Editors publisher to instructors whose schools have
Kimberly Bilotta (supervisor), adopted its accompanying textbook. Printed in
Jane Bradford, LisaStockslager, the United States of America. For information,
Dorothy P. Terry, PamelaWingrod write Lippincott Williams & Wilkins, 323 Norris-
town Road, Suite 200, Ambler, PA 19002-2756.
Designer
Lynn Foulk CHIEPG011106—040608
Illustrator
Bot Roda
Digital Composition Services
Library of Congress Cataloging-in-Publication Data
Diane Paluba (manager), Joyce Rossi Biletz,
Charting : an incredibly easy pocket guide.
Donna S. Morris p. ; cm.
Associate Manufacturing Manager Includes bibliographical references and index.
Beth J. Welsh 1. Nursing records—Handbooks, manuals,
etc. I. Lippincott Williams & Wilkins.
Editorial Assistants [DNLM: 1. Nursing Records—Handbooks. 2.
Megan L. Aldinger, Karen J. Kirk, Documentation—Handbooks.
LindaK.Ruhf WY 49 C486 2007]
RT50.C4433 2007
Design Assistant 610.73—dc22
Georg W. Purvis IV ISBN-13: 978-1-58255-538-6
Indexer ISBN-10: 1-58255-538-9 (alk. paper) 2006025286
Barbara Hodgson
5389 FM.qxp 3/15/12 11:00 AM Page iii
Contents
m- Contributors and consultants iv
-
ical, Road map to charting v
wl-
ccept-
nsid-
ons. A–C 1
ations
clini- D–H 81
new
test I–N 153
nd O–Q 213
y ad-
pro- R–Z 295
om the
l Appendices and index
opy-
ed in a The test zone 373
m or by
JCAHO National Patient Safety Goals 386
ocopy,
tten Electronic health record 392
f quo-
views Selected references 397
ed by
ve Index 399
d in
on,
rris-
56.
Data
ndex.
,
. 2.
025286
5389 FM.qxp 3/15/12 11:00 AM Page iv
Contributors and consultants
Adrianne E. Avillion, RN, DEd Merita Konstantacos, RN, MSN
President Consultant
AEA Consulting Clinton, Ohio
York, Pa.
Theresa Pulvano, RN, BSN
Peggy Bozarth, RN, MSN Nursing Educator
Professor Ocean County Vocational Technical School,
Hopkinsville (Ky.) Community College Practical Nursing Program
Lakehurst, N.J.
Cheryl L. Brady, RN, MSN
Nurse Educator Roseanne Hanlon Rafter, APRN,BC, MSN
Youngstown (Ohio) State University Director of Nursing Professional Practice
Pottstown (Pa.) Memorial Medical Center
Virginia L. Branson, RN, MA, CBCS
Program Director — Medical Office Elsa Nicklas Sanchez, RN, BSN, BA
Management Staff Development
Virginia College Meadowview Nursing Home Atlantic
Birmingham, Ala. County
Northfield, N.J.
Christine Greenidge, RN, MSN, BC
Director of Nursing Professional Practice Rita M. Wick, RN, BSN
Montefiore Medical Center Education Specialist
Bronx, N.Y. Berkshire Health Systems
Pittsfield, Mass.
iv
5389 FM.qxp 3/15/12 11:00 AM Page v
Ahoy! Welcome aboard
Charting: An Incredibly
Easy Pocket Guide.
hool,
ice
ter
Does finding time to
properly document your
patient care ever make
you feel like you’re going
to capsize?
5389 FM.qxp 3/15/12 11:00 AM Page vi
Just remember how
important charting, or
documentation, is. Accurate,
detailed charting provides a
complete record of a patient’s
care. And high-quality charting
reflects high-quality care.
Charting also helps
all crew members work
together to navigate a
patient’s care.
5389 FM.qxp 3/15/12 11:00 AM Page vii
No matter what type of charting you do,
Charting: An Incredibly Easy Pocket Guide
is filled with tons of helpful hints. Just
keep your eye out for the Help desk.
And throughout, you’ll
find Form fitting,
exemplary examples of
proper documentation.
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And last but not least,
Making a caseis here to
provide tips to help
ensure your charting is in
accordance with legal and
professional standards.
Charting helps you stay the
course when it comes to
patient care, ensuring that you
meet your final destination of
top-notch patient care.
5389ABC.qxp 3/15/12 10:51 AM Page 1
AA CC
Accountability ––
for your actions is
backed by timely,
clear, consistent, and
concise charting.
5389ABC.qxp 3/15/12 10:51 AM Page 2
2 A
A
C
Abuse suspicions N
•
• Abuse may occur in any age-group, cultural setting, or envi- •
ronment. •
• The patient may readily report abuse or fear reporting the •
abuser. •
•
• Types of abuse include:
•
–neglect
•
–physical abuse
•
–sexual abuse
•
–emotional abuse
li
–psychological abuse.
• In most states, a nurse is required by law to report signs of A
abuse in children, the elderly, and the disabled. •
• Report your suspicions to the appropriate administrator and •
agency. v
• Document suspicions on the appropriate form or in your •
nurse’s notes. b
te
• If the victim’s caregiver is present, interview the victim and
•
the caregiver separately to note inconsistencies with histo-
p
ries.
•
• An injunction can be obtained to separate the abuser and
•
the abused until circumstances can be investigated.
•
• Certain cultural practices, such as coin rubbing in Viet-
c
namese cultures, produce bruises or burns that may be mis-
•
taken for abuse.
w
• The final judgment of child abuse is decided by social
h
services and the health care team.