Transcript Documentation Methodology

DOCUMENTATION
Cheryl Bernknopf R.N.,
BScN
Assistant Director
Centauri Summer
Camp
Co- Chair OCA
Healthcare Committee
Board Member of the ACN
PURPOSE
To provide the multidisciplinary team
with a structured note format for
documenting
 To monitor the campers’ or staffs’
health and well being
 To record the care provided
 The monitor the effect of the care and
the continuity of the care.
So he’s sick…now what?
Documentation Forms
Procedure
 Black permanent ink is to be used when
charting
 Each Health Care Professional who
documents in the record must sign and initial
on the “documentation signature sheet”
 All documentation will be accompanied by
appropriate identification of the caregiver
making the entry in the chart.
 In general, staff health information should be
separate from camper client) information
Documentation Principles
Documentation must state:
 When the event happened
 What happened
 To whom it happened
 Why it happened (person or event)
 The result of what happened
Documentation Principles cont’d
 To maintain confidentiality of all
information
 Must be retrievable
 Must be neat, legible, and non-erasable.
 Must be an accurate, true and honest
account of what occurred and when it
occurred.
 Must reflect the assessment, planning,
implementation and evaluation of patient
care.
Documentation Principles cont’d
 Chart in chronological order,
documenting entries in sequence of
events. Do not document in blocks of
time i.e. August 16, 2006 1200 –
1600 hours
 Do not delete or alter an entry made
by another Health Care Professional.
Documentation Principles cont’d
 Forgotten or late entries are to be
documented on the next available space
within the Clinical Record.
 Do not use ‘whiteout’, erasers, highlighter
or entries between lines.
 Do not leave blank lines between entries.
If a blank line is inadvertently left, draw a
line through the space so that no further
entry can be documented.
Documentation Principles cont’d
 When documentation of an entry
continues from one page to the next,
the bottom of the first page is to be
signed off. Enter the date and time in
the appropriate column on the next
page and document in the Clinical
Notes “ cont’d.”
Abbreviations
 Use abbreviations according to policy
of the college of Nurses Best Practice
Guidelines or policies that have been
implemented and approved by your
camp to avoid confusion.
 Example: OD- once a day
OD- right eye
OD- overdose
Three styles of charting
 Narrative notes
 Focus charting (D.A.R)
 S.O.A.P.I.E.R
NARRATIVE NOTES
Notes are written in story format
 The story must follow the
chronological order of all events
leading up to and following the
incident
Example: Charting by exception
FOCUS CHARTING
 Notes are written in chart or D.A.R format
 Data: Subjective and/or objective
information that supports the stated focus
or describes the client status at the time of
a significant event or intervention.
 Action: Completed or planned nursing
interventions based on the nurse’s
assessment of the client’s status.
 Response: Description of the impact of the
interventions on client outcomes.
Clinical Record
Camp Having Fun
DATE
HOUR
FOCUS
D: DATA
A: ACTION
E: EVALUATION
SIGNATURE/STATUS
S.O.A.P.I.E.R. METHOD
 Notes are written using the acronym s.o.a.p.i.e.r
 S = subjective data (e.g., how does the client feel?)
 O = objective data (e.g., results of the physical exam,
relevant vital signs)
 A = assessment (e.g., what is the client’s status?)
 P = plan (e.g., does the plan stay the same? is a
change needed?)
 I = intervention (e.g., what occurred? what did the
nurse do?)
 E = evaluation (e.g., what is the client outcome
following the intervention?)
 R = revision (e.g., what changes are needed to the
care plan?)
Digital Photography….
Consider use of digital photography to:
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Send info about injury to consulting physician.
Capture record of injury for individual’s file.
Document progress of recovery process.
Provide training materials for future staff.
Show parent’s the child’s status upon return
from a visit to the doctor.
Electronic or Computer-Based System?
 Contol access so individual health
information is seen only by
designated eyes.
 Control for changes made to
individual records; alteration should
be possible only through an
ammended record which maintains
the integrity of the original record.
 Provide for an “audit” option.
TO KEEP CAMP HEALTHY & SAFE
Remember
When documenting client care, develop a system
that, at minimum, captures this information:
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Record of each person’s visits to health centre.\, the nature of
their concern, what was done to help them, evaluation of that
care, and record of who provided treatment.
Screening note from opening day.
Record of phone conversations (including attempts to contact
people) and other electronic transfer of information about a
given individual’s health needs.
Summary note of referrals to out-of-camp providers (i.e.,
dentist, mental health, MD).
Exit note- day/time of leaving program and state of health
upon leaving
REFERENCES

Charting made Incredibly Easy, Lippincott Williams & Wilkins,2006

College of Nurses of Ontario, Practice Standard Documentation,
Toronto Ontario. 2005

E-Learning Centre, College of Nurses of Ontario 2006. www.cno.org

Lampe, S., Focus Charting Documentation for Patient-Centered Care,
Minneapolis, Minnesota, 1997

Laura Burke and Judy Murphy, Charting By Exception Applications,
Milwaukee, Wisconsin. 1995 .

Erceg, L.E., & Pravda, M. (2009). The Basics of Camp Nursing,
Monteray, CA: Healthy learning