Factual
Factual -charting what is really the case instead of your interpretations or your reaction to it. It should be objective (what you see), rather than subjective (what you did not see).
Situation:
You are passing morning medications when you hear a patient yelling“Help! Help!” You run into the room to find the patient is on the floor on her back with her walker beside her. The patient denies hitting her head, but is complaining of new back and right wrist pain. You do a quick assessment to look for any other injuries or new pains. The doctor is notified. The doctor comes to the room and determines that it is okay to assist the patient up and get her back in bed. How would you chart this to assure that it is factual information? Remember subjective VS. objective. Chart only the FACTS, and not what you THINK happened. Chart only what you KNOW happened and quote anything the patient says.
What not to do: Patient fell getting out of bed using walker in her room. I think she may have tripped over her fall mat. Patient did not hit her head. Doctor called and came to room. Patient has back and wrist pain. Patient put back in bed.
What to do: Patient found lying on the floor. Doctor notified. Patient denies hitting her head. Patient complains of new back and right wrist pain. No other injuries noted. Doctor in room. Patient is assisted back in bed.
Tips on Charting Factually
The "What not to do" charting example stated "patient did not hit her head" and "I think she may have tripped over her fall mat." This was not seen, you can only chart what you saw or what the patient states. Be sure to chart the patient was found and the patient stated she did not hit her head. You want your charting to reflect that you did not witness the event.
Accurate
Accurate as defined by google means "correct in all details.”
Situation:
You are receiving a direct admit. Upon the patient’s arrival you do a head-to-toe assessment and ask your tech to get vitals. VS read as follows: BP 184/102, HR 116, temperature 98.8, Respirations 18, O2 sats 98% on room air. The patient is able to tell you his name, DOB, year, but does not know where he is at. You notice his pupils are equally reactive. The patient has a regular heartbeat and will be put on telemetry, but you notice swelling to left lower extremity. When pressed it takes about 5 second for the indentation to return to normal. You listen to the patient’s lungs and notice they are clear, but the breath sounds are not quite as loud as normal. The patient complains of a dry cough and shortness of breath when he walks up the stairs or for long distances. You auscultate the patient’s abdomen and can not hear anything. The patient says he has not had a bowel movement in over 4 days. You palpate his abdomen to feel it is hard and notice it is rounded. The patient denies nausea, but does say he has vomited once or twice over the last couple of days, and that it “hits him out of nowhere.” The patient states that he is “scared to eat because I do not want to throw it back up.” The patient denies any symptoms while urinating and says he “has no problems peeing.” The patient has a right BKA and uses a prosthesis and walker to walk. He is stable while walking, but prefers someone to help him while walking because he “feels weak and shaky.” In his history you read the patient has a history of depression and takes antidepressants at home. You start a 20g peripheral IV to his left forearm.
Remember to be ACCURATE in your charting. This is a lot of information to chart so double check to make sure everything is accurate and true.
What Not to do: Patient awake and talking. Vital sign normal. Patient placed on telemetry. Patient SOB at times. Denies bowel movement for several days. Patient vomits and has nausea, patient scared of throwing up again. Patient right leg is amputated. No problems with peeing. Patient walks with help and has depression. Iv started to left arm.
What to do: Patient AAOx2. Reoriented to place. Vital signs BP 184/102, HR 116, R 18, T 98.8, O2 sats 98% on RA. PERRLA. Heart rate regular, telemetry applied. Lung fields clear with diminished breath sounds bilaterally. non-productive cough noted. Pt c/o SOB when walking up stairs and long distances. Hypoactive bowel sounds auscultated. Denies bowel movement x 4 days. Abdomen rigid and round. Denies nausea at present but states has vomited 1 to 2 times over the past couple of days. Denies Right BKA. Pitting edema to LLE. Patient uses prosthesis and walker to ambulate. Patient states he feels week and shaky when ambulating and requires help. Patient has history of depression. 20 gauge IV started in left forearm.
Tips on Charting Accurately
Factual -charting what is really the case instead of your interpretations or your reaction to it. It should be objective (what you see), rather than subjective (what you did not see).
Situation:
You are passing morning medications when you hear a patient yelling“Help! Help!” You run into the room to find the patient is on the floor on her back with her walker beside her. The patient denies hitting her head, but is complaining of new back and right wrist pain. You do a quick assessment to look for any other injuries or new pains. The doctor is notified. The doctor comes to the room and determines that it is okay to assist the patient up and get her back in bed. How would you chart this to assure that it is factual information? Remember subjective VS. objective. Chart only the FACTS, and not what you THINK happened. Chart only what you KNOW happened and quote anything the patient says.
What not to do: Patient fell getting out of bed using walker in her room. I think she may have tripped over her fall mat. Patient did not hit her head. Doctor called and came to room. Patient has back and wrist pain. Patient put back in bed.
What to do: Patient found lying on the floor. Doctor notified. Patient denies hitting her head. Patient complains of new back and right wrist pain. No other injuries noted. Doctor in room. Patient is assisted back in bed.
Tips on Charting Factually
The "What not to do" charting example stated "patient did not hit her head" and "I think she may have tripped over her fall mat." This was not seen, you can only chart what you saw or what the patient states. Be sure to chart the patient was found and the patient stated she did not hit her head. You want your charting to reflect that you did not witness the event.
- If subjective information is charted be sure it came directly from a family member, patient, or staff member that was in the room.
- If the patient says anything, such as what she was doing when she fell, be sure to include the statements in quotations in your charting.
- If you do witness the event, still only chart what you see happen, and not what you think.
Accurate
Accurate as defined by google means "correct in all details.”
Situation:
You are receiving a direct admit. Upon the patient’s arrival you do a head-to-toe assessment and ask your tech to get vitals. VS read as follows: BP 184/102, HR 116, temperature 98.8, Respirations 18, O2 sats 98% on room air. The patient is able to tell you his name, DOB, year, but does not know where he is at. You notice his pupils are equally reactive. The patient has a regular heartbeat and will be put on telemetry, but you notice swelling to left lower extremity. When pressed it takes about 5 second for the indentation to return to normal. You listen to the patient’s lungs and notice they are clear, but the breath sounds are not quite as loud as normal. The patient complains of a dry cough and shortness of breath when he walks up the stairs or for long distances. You auscultate the patient’s abdomen and can not hear anything. The patient says he has not had a bowel movement in over 4 days. You palpate his abdomen to feel it is hard and notice it is rounded. The patient denies nausea, but does say he has vomited once or twice over the last couple of days, and that it “hits him out of nowhere.” The patient states that he is “scared to eat because I do not want to throw it back up.” The patient denies any symptoms while urinating and says he “has no problems peeing.” The patient has a right BKA and uses a prosthesis and walker to walk. He is stable while walking, but prefers someone to help him while walking because he “feels weak and shaky.” In his history you read the patient has a history of depression and takes antidepressants at home. You start a 20g peripheral IV to his left forearm.
Remember to be ACCURATE in your charting. This is a lot of information to chart so double check to make sure everything is accurate and true.
What Not to do: Patient awake and talking. Vital sign normal. Patient placed on telemetry. Patient SOB at times. Denies bowel movement for several days. Patient vomits and has nausea, patient scared of throwing up again. Patient right leg is amputated. No problems with peeing. Patient walks with help and has depression. Iv started to left arm.
What to do: Patient AAOx2. Reoriented to place. Vital signs BP 184/102, HR 116, R 18, T 98.8, O2 sats 98% on RA. PERRLA. Heart rate regular, telemetry applied. Lung fields clear with diminished breath sounds bilaterally. non-productive cough noted. Pt c/o SOB when walking up stairs and long distances. Hypoactive bowel sounds auscultated. Denies bowel movement x 4 days. Abdomen rigid and round. Denies nausea at present but states has vomited 1 to 2 times over the past couple of days. Denies Right BKA. Pitting edema to LLE. Patient uses prosthesis and walker to ambulate. Patient states he feels week and shaky when ambulating and requires help. Patient has history of depression. 20 gauge IV started in left forearm.
- RA means room air.
- PERRLA means the pupils are reacting normally to light and movement.
- SOB means shortness of breath.
- BKA means below the knee amputation.
- LLE means left lower extremity, or left leg.
Tips on Charting Accurately
- When charting vital signs, don't say normal. What is normal for one person may not be normal for the other person.
- Give accurate details. Patient SOB at times. Ask the patient when does the SOB of breath occur.
- Stay away from vague statements. Patient has not had bowel movement for several days. Be sure to ask how many days.
- Be very accurate with all charting. If the patient gives vague answers, follow through and get all the facts to chart.
- Ask question to be as accurate as possible. RN also means "Real Nosey." It is our job to be nosey.
Picture from
Cynthia Dusseault; http://scrubsmag.com/do-you-make-these-3-common-charting-mistakes/; “Do you make these 3 common charting mistakes?”
1 Nov 2011; Web; accessed 13 Nov 2014.