💓 Savvy NurseLouvri aplikasyon an

🩺 Prensip Debaz yo, Rapid · Leson 3 sou 5 · 6 min

Ekri nan Dosye a nan Yon Fason ki Pwoteje Lisans Ou

Charting That Protects Your License

✍️ Nan twa an, yon avoka ka li nòt ou te ekri pandan yon shift ou pa ka sonje. Ekri nan dosye a se pa senp papye. Se sèl temwen ou.

✍️ Three years from now a lawyer may read your note from a shift you cannot remember. Charting is not paperwork. It is your only witness.

💡 Ide prensipal

Objektif, alè, konplè epi onèt. Make antre reta yo, korije erè yo nan transparans, epi kenbe rapò ensidan yo deyò dosye a.

Objective, timely, complete and honest. Label late entries, correct errors transparently, and keep incident reports out of the chart.

🧠 Poukisa sa enpòtan

Ekri nan dosye a OBJEKTIVMAN: sa ou te wè, mezire ak fè, ak pwòp mo pasyan an lè sa enpòtan, san opinyon oswa etikèt tankou soul oswa k ap chèche dwòg. Ekri nan dosye a an TAN REYÈL, janm pa anvan swen an. Yon ANTRE RETA otorize men li dwe make kòm antre reta ak dat ak lè aktyèl la epi lè evènman an te rive vre a. Korije yon erè sou papye ak yon sèl liy ki travèse l, inisyal ou ak dat la; janm pa efase, kouvri nèt oswa itilize likid koreksyon. Nan yon dosye elektwonik, itilize fonksyon koreksyon sistèm lan; janm pa pataje koneksyon ou. Pa kite okenn espas vid. Ekri nan dosye a lè yon pasyan REFIZE swen, sa ou te eksplike l, epi ki moun ou te avèti. RAPÒ ENSIDAN yo pase nan pwosesis kalite etablisman an; yo pa mete yo nan dosye a epi dosye a pa dwe mansyone ke yo te depoze yon rapò, sèlman fè yo sou sa ki te rive ak swen yo te bay la.

Chart OBJECTIVELY: what you saw, measured and did, in the client's own words where relevant, with no opinions or labels like 'drunk' or 'drug-seeking'. Chart in REAL TIME, never ahead of care. A LATE ENTRY is allowed but must be labeled as such with the current date and time and the time the event actually occurred. Correct a paper error with a single line through it, your initials and the date; never erase, obliterate or use correction fluid. In an electronic record, use the system's amendment function; never share your login. Leave no blank spaces. Chart a client's REFUSAL of care, what you explained, and whom you notified. INCIDENT REPORTS go through the facility's quality process; they are not placed in the chart and the chart should not mention that one was filed, only the facts of what happened and the care given.

🏥 Nan lavi reyèl

🧾 Yon pasyan tonbe a 0215. Enfimyè a ekri nan dosye a a 0220: yo jwenn pasyan an atè bò kabann nan, li di li glise pandan l t ap leve. Alèt, oryante ×3, okenn blesi vizib, BP 128/76, HR 84, RR 18, SpO2 97% sou lè chanm lan, yo avèti founisè a a 0218, yo ede l retounen nan kabann nan, alam kabann nan aktive. Yo depoze yon rapò ensidan apa. Nòt la gen fè yo, lè yo ak aksyon yo, epi anyen sou blame moun. Se yon nòt ki kenbe fèm.

🧾 A client falls at 0215. The nurse charts at 0220: 'Client found on floor beside bed, states "I slipped getting up." Alert, oriented ×3, no visible injury, BP 128/76, HR 84, RR 18, SpO2 97% on room air, provider notified 0218, assisted back to bed, bed alarm activated.' An incident report is filed separately. The note contains facts, times and actions, and nothing about blame. That is a note that holds up.

📌 Sa pou retni

  • Fè, mezi ak sitasyon; okenn opinyon oswa etikètFacts, measurements and quotes; no opinions or labels
  • Antre reta yo make; erè yo resevwa yon sèl liy, inisyal ak datLate entries are labeled; errors get a single line, initials and date
  • Rapò ensidan yo rete deyò dosye a epi yo pa mansyone yo ladan lIncident reports stay out of the chart and are not referenced in it

✅ Teste tèt ou

Ki antre dokimantasyon ki pi apwopriye?Which documentation entry is most appropriate?
  1. 'Pasyan an sanble yon risk pou tonbe aswè a, pwobableman akòz tout bwè li bwè a.''Client seems like a fall risk tonight, probably because of all the drinking.'
  2. 'Pasyan an soul epi li pa koopere.''Client is drunk and uncooperative.'
  3. 'Pasyan an di, "Mwen te bwè sis byè aswè a," li pale ak pawòl lou, demach li pa stab.''Client states, "I had six beers tonight," speech slurred, unsteady gait.'
  4. 'Pasyan an te grosye ak pèsonèl la.''Client was rude to staff.'

Repons: C · 'Pasyan an di, "Mwen te bwè sis byè aswè a," li pale ak pawòl lou, demach li pa stab.'

Sitasyon ak obsèvasyon yo objektif. Etikèt ak espekilasyon pa objektif. Lè w rele pasyan an soul epi li pa koopere, se yon etikèt jijman olye dokimantasyon objektif, kidonk li pèdi devan deklarasyon site yo ak obsèvasyon yo.

Quotes and observable findings are objective. Labels and speculation are not. Calling the client drunk and uncooperative is a judgmental label rather than objective documentation, so it loses to quoted statements and observed findings.

Yon enfimyè reyalize yon medikaman 1400 pa t janm dokimante. Kounye a li 1800. Kisa enfimyè a dwe fè?A nurse realizes a 1400 medication was never documented. It is now 1800. What should the nurse do?
  1. Mande yon kolèg ekri l nan dosye aAsk a coworker to chart it
  2. Mete antre a nan plas 1400 la kòm si li te ekri l lè sa aInsert the entry in the 1400 slot as if written then
  3. Kite l deyò dosye a pou evite konfonn pwochen shift laLeave it out of the record to avoid confusing the next shift
  4. Ekri yon antre reta ki make ak tou de lè yoWrite a late entry labeled with both times

Repons: D · Ekri yon antre reta ki make ak tou de lè yo

Antre reta yo akseptab lè yo make onètman ak lè yo te ekri yo ak lè evènman an te rive. Lè w mete antre a nan plas 1400 la kòm si li te ekri l lè sa a, ou defòme lè nòt la te fèt, sa vle di falsifye dosye a.

Late entries are acceptable when labeled honestly with when they were written and when the event occurred. Inserting the entry in the 1400 slot as if written then misrepresents when the note was made, which is falsifying the record.

Apre yon erè medikaman, kijan enfimyè a dwe jere rapò ensidan an?After a medication error, how should the nurse handle the incident report?
  1. Depoze rapò a apa epi ekri sèlman fè yo nan dosye aFile the report separately and chart only the facts
  2. Dokimante nan dosye a ke yo te ranpli yon rapò ensidanDocument in the chart that an incident report was completed
  3. Sote rapò a paske erè a pa t fè pasyan an malSkip the report because the client was not harmed by the error
  4. Depoze rapò a epi mete yon kopi nan dosye pasyan anFile the report and place a copy in the client's chart

Repons: A · Depoze rapò a apa epi ekri sèlman fè yo nan dosye a

Rapò ensidan yo se dokiman kalite entèn. Dosye a anrejistre sa ki te rive ak sa yo te fè, janm pa ke yon rapò egziste.

Incident reports are internal quality documents. The chart records what happened and what was done, never that a report exists.

Kòmanse leson sa a gratis →

Kesyon tankou NCLEX, XP ak seri jou nan aplikasyon an, an angle ak èd an kreyòl. Pa bezwen enskri.

Plis nan Prensip Debaz yo, Rapid

🔗 Leson ki gen rapò