RELATED LITERATURE

According to Janice Rider Ellis ( 1980, 15-28), nurses should basically try to

provide a clear and concise record of the nursing process in relation to individual

patient. She made mention about the mechanics of charting: a.) As a legal record, a

chart must conform to certain legal standards. All entries must be in ink so that changes

are noticeable and the record is permanent. Your facility may specify that particular

color of ink be used. Legibility is obviously critical; statements that are not legible are

not usable. b. ) if you make an error draw a line in the incorrect entry so that it remains

legible. In the space above it notate “Error” and your initials. Recently, attorneys have

recommended that a brief note has to the nature of the error would be helpful If the

chart were needed in a legal proceeding. In that case, you might chart right “charted on

wrong page” and your initials. c.) do not leave blank spaces if you are using the

narrative forms. Draw a straight line though any space to prevent any later entries from

being made in front of your signature. d.) notations of time and date are important for

health care reasons and as well as for legal reasons. Time sequences can be crucial

and certain problems. e.) for signature use first initial an full last name allowed by

abbreviation of your position.

Traditionally, a great deal of specialized terminology has been used in charting.

In addition, there are traditional patterns of word usage. As a student progresses in their

nursing and related studies they pick up a large vocabulary in which they must be
careful in using effectively and correctly. Abbreviations are used in charting to save time

and space. When in doubt, use the full term since it will be understood regardless of

local customs. Sentences are typically reduced o their essential components in charting.

The articles (a, an, the)and even verbs may be omitted when it represent the patient

because the entire chart is about an individual patient.

Barbara Kozier, et al (2004) emphasized the importance of recording since the

client’s record is a legal document & may be used to provide evidence in court. She

stated that health care personnel must not only maintain the confidentiality of the client’s

record but also meet the legal standards in the process of recording.

The following factors were enumerated as the general guidelines in recording: (1)

Date and time. The date & time of administration should be documented. This is

essential not only for legal reasons but also for client safety. The time should be

recorded in a conventional manner or according to a 24-hour clock to avoid confusion

about whether a time was AM or PM; (2) Timing. As a general rule, documenting should

be done as soon as possible after an assessment or intervention. No recording should

be done before providing nursing care. Health care agencies may also have different

policies about the frequency of documenting and that it may also depend as the client’s

condition indicates ; (3) Legibility. All entries must be legible and easy to read to

prevent interpretation errors. Hand printing or easily understood handwriting is usually

permissible but the agency’s policy about handwritten recording must be the one
followed; (4) Permanence. All entries on the client’s record are made in dark ink so that

the record is permanent and changes can be identified. The agency’s policies about the

type of pen and ink used for recording should be followed; (5) Accepted Terminology.

Many abbreviations are standard and used universally, others are used only in certain

geographic areas. Health care facilities are required to supply an approved list of

abbreviations to prevent confusion. The nurse should know and use only the approved

list of abbreviations at the facility to avoid putting the client at potential risk; (6) Correct

Spelling. Incorrect spelling gives a negative impression to the reader and decreases the

nurse’s credibility ;( 7) Signature. Each recording on the chart is signed by the nurse

making it. The signature should also include the name and title; (8) Accuracy. The

client’s name and identifying information should be stamped or written on each page of

the clinical record. When a recording mistake is made, a line is drawn through it and the

words “mistaken entry” is written above or next to the original entry; (9) Sequence.

Events must be documented in the order which they have occurred; (10)

Appropriateness. Only information pertinent to the client’s healthcare should be

recorded; (11) Completeness. Not all data that a nurse obtains about a client can be

recorded. However, the information that is recorded needs to be complete and helpful to

the client and health care professionals. Care that is omitted because of the client’s

condition or refusal of treatment must also be recorded. Document what was omitted,

why it was omitted, and who was notified; (12) Conciseness. Recordings need to be

brief as well as complete to save time in communication; and (13) Legal Prudence.

Accurate complete documentation should give legal protection to the nurse; the client’s
other caregivers, the healthcare facility, and the client. Admissible in court as a legal

document, the clinical record provides proof of the quality of care given to a client.

Author Lois White enumerated several elements in producing effective

documentation. Some of those are: (1) Accurate, Complete, and Objective. Record just

the facts---exactly what you see hear and do. Remember if it is not charted it was not

done ;( 2) Date and Time. Be sure each entry is dated and has a specific time. Note the

exact time of sudden changes in a clients conditions, nursing actions, and other

significant events. Never chart in blocks of time; (3 Use of Appropriate Forms. Forms

used are not the same from facility to facility; (4) Identification of Patient. Each page of

the client’s record is to have the client’s name on it. This aids in preventing confusion

and helps ensure that information is charted on the correct record; (5) Use of Standards

Abbreviations. Each health care facility has a list of approved abbreviations and

symbols to be used in documenting information on their client records. This is to meet

the Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards

and regulations in many states. (6) Correct Spelling. Misspelled words on client records

may be confusing and certainly convey a sense of unprofessionalism; (7) Legible

Writings. Sloppy writing hinders communication and possible errors in client care can

occur. Trying to decipher illegible handwriting wastes time creates a poor impression of

the person who did the writing any damages that person’s credibility. Print rather than

use cursive writing as it is usually easier to read; (8) Correcting Errors Properly. Know

and follow the facility’s policy for correcting errors. Generally, drawing a single line

through the mistaken entry is made so that what was written can still be read. Above it,
“Mistaken Entry’ is written, followed by the initials and the date; (9) Write on every line.

Each line should be filled completely. There should be no blank lines or partially blank

lines. A line should also be drawn through the empty part of the line to prevent others

from inserting information later that may change the meaning of the original

documentation. On forms, when information requested does not apply to a particular

client, write “NA”(not applicable) or draw a line through the space to indicate that every

item on the form has been addressed.; (10) Chart Omissions. Whenever a part of the

chart is omitted, document the reason why; (11) Sign each entry. Each entry is to be

signed with the first name or initial, full last name, and professional licensure. The

signature should be at the end of the entry of the far right side.

The book Mastering Documentation authored by Springhouse Corporation

specified the following guidelines in documenting drug administration: (1) know and

follow the facility’s policies and procedures for recording drug orders and charting rug

administration; (2) all drug orders should include the patients full name, date, drug’s

name, dose, administration route or method, and frequency; (3) Write legibly; (4) use

only standard abbreviations approved by the facility. When doubtful about an

abbreviation write out the word or phrase; (5) After administering the first dose, sign

your full name, licensure status and initials in the appropriate space on the Medication

Administration Record(MAR).
 Lippincott Williams in his book entitled “Charting Incredibly Easy” stated that

medication administration record is a part of most charting systems. It may be included

in the Medication Kardex, or it may be on separate sheet. In either case, it’s the central

record of medication orders, their execution and is part of the patient’s permanent

record. He specified the following guidelines on charting medications: (a) Follow your

facilities policies and procedures for recording drug orders and administrations.

(b)Record the patients full name, medical record number, and allergy information on

each MAR. (c) Immediately document the drugs name, dose, route of administration,

frequency, the number of doses ordered or the stock date (if applicable), and the

administration time for doses given. (d)Write legibly.(e)Use only standard abbreviations.

Remember that JCAHO prohibits the use of certain abbreviations (those that appear on

the do not use list). When in doubt, write out the word or phrase. (f)After administering

the first dose, sign your full name, licensure status, and initials in the appropriate space.

(g)Record the drug administration immediately after each dose in administered so that

another nurse doesn’t inadvertently repeat the dose.(h)If you chart by computer, do so

right after giving each drug – expecially if you don’t use printouts as a back up. Doing so

gives all team members access to al latest drug administration data. (i)If a specific

assessment parameter must be monitored during administration of a drug, document

this requirement on the MAR. For example, when digoxin is administered, the patients

pulse rate must monitored and charted on the MAR. (j)If you didn’t give a drug, circle

the time and document the reason for the omission. (k)If you suspect that a patients

illness, injury or death was drug related, report this to the pharmacy department, who

will relay the information to the food and drug administration.

 Student nurses are an important part of the patient care team and can enrich

patients' experiences during hospitalization. However, some circumstances may

increase the chance of their involvement in medication errors. The Institute for Safe

Medication Practices (ISMP) has analyzed medication errors by student nurses, and

discovered that a distinct set of error-prone conditions or medications can make

mistakes involving students more likely.Some student-related errors are similar in origin

to those that involve seasoned licensed healthcare professionals, including

misinterpreting abbreviations and misidentifying drugs due to look-alike packages or

labels. But by examining data from the United States Pharmacopeia-ISMP Medication

Error Reporting Program and the Pennsylvania Patient Safety Reporting Program,

ISMP found that a significant number of other errors stem from more system-related

problems, some of which are unique to environments where students and hospital staff

are caring together for patients. One major system problem is the duality of patient

assignments; patients assigned to student nurses are also assigned to staff nurses.

Although this policy is necessary, it makes communication breakdowns regarding who

will administer which prescribed medications and when more likely. Communication

between students, nursing instructors, and staff needs to be planned carefully to ensure

that safety issues are taken into consideration. With both staff nurses and students

administering medications to the same patients, dose omissions or extra doses have

been administered because students or staff nurses have not properly documented or

reviewed prior documentation of drug administration. (www.medicalnewstoday.com)

 Documentation is an ongoing process that starts the moment a person enters

into your care until the time they leave. It is done so that communication of information

between and among the health care professionals attending to the patients would be

accurate. Particular guidelines regarding documentation should be followed: (1) Check if

you have the correct patient’s record/ chart before you write anything; (2) Write clearly;

(3) Never use pencil;(4) Document completely, concisely and accurately; (5) Do not use

whiteouts or erase an entry if written incorrectly. A single line should be drawn through it

& should be labelled as a mistaken entry; (6) Empty lines or spaces should be filled in

with a single line to prevent writing by someone else; (8) Avoid using vague terms, be

specific; (9) If a mistake in delivering care is committed, document the error, the

resident’s outcome and who was contacted to help fix the situation; (10) Never record

one’s opinions; (11) Don’t use language that suggests a negative attitude toward

someone. In recording interactions with the doctor or other

Health care professionals, some of the guidelines to follow are: a) Record each phone

call to or from a healthcare provider, including date and time and who you spoke with. b)

Document information from appointments with care providers such as doctors, home

health nurses, therapists, etc. c)If you are waiting for a return phone call, document

each time you contacted the office. Specific guidelines for documenting medications

also include: (1) Document the time you gave a medication. Unusual or unexpected

reactions should also be recorded; (2) Document a resident’s refusal to allow a

treatment or take a medication; (3) Write the reasons why the person refused and use

the person’s own words in quotations if possible. Document that you reported the

refusal to the prescriber; (4) If you don’t give a medication, circle the time, initial and
date and give the reason for the omission.

(www.oregon.gov/DHS/spd/provtools/nursing/studyguides/documentation)

National In- Patient Medication Chart identified general instructions regarding

documentation of medications. These are the following: a)Write legibly in ink. Water-

soluble ink should not be used (eg fountain pens) �“Black”ink is preferred, except for

clinical pharmacists “Purple”�Medication order valid only if prescribing medical officer

enters all required items�All information is to be PRINTED�Only acceptable

abbreviations to be used�Separate order required for each drug �No erasers or

“whiteout” b)Print legibly; c)Enter Frequency and then enter administration times; d)Use

only Generic Drug Names, except combination products; e)Use “accepted”

abbreviations, leave the rest; f)Avoid decimal points (write 500mg instead of 0.5g) ;

g)Never use terminal zeros (1mg instead of 1.0mg)and h)Reconcile your medication

orders.