RECORDKEEPING

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RECORDKEEPING

• RsCr 220
• First year Respiratory Care

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Medical Record

• Is a written picture of occurrences and
  situations pertaining to a patient throughout his
  or her stay in the hospital

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Confidentiality

• Are the property of the institution
• Strictly confidential
• Content of the patients record are not to be
  read or discussed by anyone except those directly
  caring for the patient in the hospital

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Legal Document

• Law requires that a record be kept
• It should be meaningful for days, months and
  years later in case it is used in court

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Legal Aspects

• Documentation of the care to a patient means that
  patient care was given
• NO documentation means that care was not given
• If the RCP does not document care given
  (assessment, interventions and evaluation) then
  he may be accused of patient neglect

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Patient Care Standards

• The hospital (through the Respiratory Care
  Department) generates standard of care for
  patients
• If therapist doesnt document those standards
  then he/she is negligent

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General Rules

• Should be legible handwritten or printed for
  everyone else to read and understand
• Sign the entry with your first initial, last name
  and title (D. Student SRT)
• Have your therapist/supervisor countersign
• Do not use ditto marks
• Do not erase

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General Rules

• If a mistake is made, do not scribble it out
• Draw a single line through it write
  error/correction and initial the entry
• Be exact in recording time, effects and results
  of all treatments and procedures
• Record patients complaints and general behavior

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General Rules

• Be specific with descriptions
• Record Expiratory wheezes in the upper lobes
  bilaterally rather than wheezing
• Describe clearly the consistency and amount of
  secretions Copious amounts of blood tinged tan
  colored secretions

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General Rules

• Leave no blank lines. Draw a single line through
  the center of an empty line
• Use only standard abbreviations
• No Suffering from terminal PIA
• Learn to spell and use proper grammar (only in
  the present tense never the future)

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SOAP Charting

• SUBJECTIVE information obtained from the patient,
  his or her familyOBJECTIVE or observable
  information from test or physical examination
• Documentation should reflect the standards of
  patient care
• ASSESSMENT which refers to the analysis of the
  patients problem
• PLAN of action to be taken to resolve the problem

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Objective Data

• Airway breath sounds
• Cough
• Secretions
• Chest X-ray
• ABGs
• Saturations

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Common Assessments

• Bronchospasm
• Secretions in the large airways
• Poor secretion clearance
• Excessive secretions
• Pulmonary edema
• Acute ventilatory failure
• Hypoxemia

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Common Plans

• Bronchodilator treatment
• Bronchial hygiene
• Hyperinflation therapy
• Oxygen therapy
• Cool / heated mist
• Mechanical ventilation
• Treat underlying cause

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The End

• Thats all folks