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Patient charting is notate why the patient is there in order to have a record of their health status, helps with the providers treatment plans, and the patient’s diagnosis (Mississippi, 2022). The patient documentation may include the patients medical test results, medical history, medication history and currently. These documentation will help everyone who is a part of the patients healthcare team provide the highest quality of patient care. The Providers, and nurses rely on good patient charting to help understand the patients needs in order to deliver the right medications and right testing (Mississippi, 2022). As a new worker in the medical field the type of charting I was introduced to in school and externship was the SOAP notes method. There are other types of methods for charting such as the PIE charting. PIE is very easy to use and simple but I preferred the SOAP notes because it is more structured, includes the patients vital signs all together unlike the PIE chart who will only show the patients problem, the intervention to the problem and the plan. SOAP notes have already been assigned its role so when you check the charting for the patient you don’t have to read the whole thing to know what the plan is for the patient. To work efficiently you have to be well structured and organized, that is why I pick the soap notes. I use the soap notes method as a CMA, this keeps me right on track and not take the appointment time off from the provider since I am only there to get their vitals, update their medications, medical history, and notate any other extra issues before the patient see’s the provider.
Mississippi College. (2022, February 21). What Is Charting and Why Is It so Important? Mississippi College, A Christian University. https://online.mc.edu/degrees/nursing/rn-to-bsn/patient-charting-and-health-information/
Patient information in acute care, long-term care, and other clinical settings are now electronic. It uses internet technology for secure access by providers, nurses, and other healthcare team members to maintain patient confidentiality. Nurses and healthcare team members are legally required to document patient care. Documentation should be objective, factual, professional, and use proper medical terminology, grammar, and spelling. Documentation is used to ensure continuity of care for every medical team member for each shift. It monitors standard care for quality assurance activities and provides information for reimbursement purposes by insurance companies. It also may be used for research purposes or in some instances, for legal concerns in a court of law.
Medical documentation by nurses includes recording patient assessments, writing, progress notes, and creating or addressing information included in the nurse’s care plans. Common formats used to document patient care are Charting by Exception, Focused DAR charting, Narrative notes, SOMPIE progress notes, patient’s discharge summaries, and Minimum Data Set (MDS) charting. After researching different types of charting, I decided to go with Focused DAR charting. Focused DAR Charting is a type of progress note that is commonly used in combination with Charting by Exception. DAR stands for Data, Action, and Response. DAR Charting organizes notes about patient’s health changes, patients concerns, or specific events.
The focus is identified during the assessment, then nurses note the specific actions they took as well as how the patient responded to those actions. Focused DAR notes are brief, each note focuses on a patient problem, then efficiently makes it easier to document. The best advantage that Focused DAR charting has is that it is less time-consuming and convenient when handling patient’s information to add to the EMR. This charting process follows the nurse’s process very closely but can be a little confusing, especially for new nurses. I personally don’t think that Focused DAR charting would work in all areas of medicine.
In the medical field, every medical professional has a specific role in the medical facility. It is mandatory for every individual medical professional in their designated position to follow procedures, rules, regulations, and guidelines that come with their position. Each medical professional has their own charting system, therefore, they must abide by that system. After doing my research about each form of charting, I noticed that certain medical staff would maneuver back and forth from each charting that I previously listed. When one charting process doesn’t work for them or if they are struggling with a particular charting system, they would use one that works best for them. Everybody has their own way of documenting information, but in my opinion, each individual should stick to what is mandatory.
Overall, I enjoyed learning and researching each different form of medical charting and how each process is used to document a patient’s information. Hopefully, everyone can relate to me in some way and I am looking forward to reading your responses to my discussion.
Nursing, O. R. F. (n.d.). 2.5 Documentation – Nursing Fundamentals. Pressbooks. Retrieved August 7, 2022, from https://wtcs.pressbooks.pub/nursingfundamentals/chapter/2-5-documentation/
Correll, R. M. (n.d.). Nurse Charting 101. Berxiâ¢. Retrieved August 7, 2022, from https://www.berxi.com/resources/articles/nurse-charting-101/
Gallego, G. (2021, May 28). What is a Medical Chart? Continuum. Retrieved August 7, 2022, from https://www.carecloud.com/continuum/what-is-a-medical-chart/
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