What to Chart When You Can’t Chart Everything: Practical Tips for Nursing Documentation

The variation in electronic health records leaves quite a bit of latitude for health care providers to document patient care. Some electronic health records provide many options to capture patient care, while others provide very few options, and both are inherently known for not capturing enough patient care necessary to demonstrate that a standard of care has been met.

An example of documentation that is frequently seen in medical records and is often presented as a problem in the courts has to do with skin breakdown. The prevention of skin breakdown fundamentally requires that patients who are not able to adjust their position are turned every two hours. According to the National Pressure Advisory Panel, many factors are taken into consideration when evaluating a tissue injury, but the first and primary intervention for all patients regardless of “other factors” is to turn patients. When a tissue injury develops (bed sore), stage II, stage III, stage IV, or suspected deep tissue injury, the scrutiny of care will include proving that the patient was, at a minimum, turned to even get close to meeting the standard of care for the prevention of wounds.

Nursing negligence may be alleged for failing to turn the patient every two hours. In addition, if the medical record does not show that the nursing plan of care includes an actual or potential problem addressing alteration in skin integrity it is assumed the turning patients was not done. If a wound develops, it is possible that a correlation can be made between the nurses’ failure to turn the patient led to and contributed to the skin breakdown.

When the medical record clearly demonstrates the patient was turned every two hours and still developed advancing staged wounds, then “other physical factors” are considered as significantly contributory. If the other physical factors do not exist then the documentation may be considered falsified charting. Other physical factors include, but are not limited to: lab results, diabetes, coronary artery disease, previous surgeries, age, infection, etc.

Examples of when care has not been documented and caused additional scrutiny of care are the following:

• Head of bed elevated. Elevation recorded with specific degrees is important when care involves aspiration precautions, limiting sheer, or hemodynamic measurements.

• Response to titration of medications in a critical care area. Titration of medication is expected to occur until a desired effect is attained particularly when orders are written in a protocol format. Medication management recorded in the medical record must reflect appropriate clinical judgment by the nurse.

• Fall prevention interventions. It is not enough to simply record or check off: fall prevention protocol in place. Should a patient fall on your shift, will the records show that what is listed in the protocol was done to prevent the fall? Be specific regarding interventions used when caring for patients determined to be at a higher risk for injury.

Medical record entries must be factual, accurate, complete, and timely. Use the FACT rule. It is very easy to remember.

FACTUAL means there must be enough detail of the facts that the story depicting the patient’s care is clear. Facts are clinical findings a nurse knows to be true. Facts may be lab results, clinical assessment, medications, vital signs, and it could also mean what the patient says. Put what a patient says in “quotations”. First-hand knowledge is another way to determine what should be charted. The best practice is to chart only that which is known to be true. An exception to this practice is during a crisis intervention when the situation utilizes a scribe as one might do during a code or a rapid response. The scribe charts as the events unfold and the documentation is reviewed for accuracy after the patient is stabilized by the health care team.

ACCURATE means the facts must be recorded correctly. The labs must be entered precisely if they are not crossed over through an electronic health record portal system. The movement of a decimal point just one place when recording a medication administered can convey that the dose administered was 10 times or even 100 times more than the dose ordered. Imagine if a record reflected that a nurse administered 10 mg of Atropine instead of 1 mg. How would this error be defended if a catastrophic result seems to be related to the medication error?

COMPLETE medical record entries are thorough entries. Don’t leave the reader guessing about patient care provided. Check the completeness of medical record entries by using: “O P Q R S T”.

“O” is for onset.

“P” is for precipitating or aggravating factors.

“Q” is for quality or quantity

“R” is for radiating

“S” is for situation

“T” is for time (time of day)

The final term, TIMELY. Medical record entries are expected to be written contemporaneously. All that means is charting as soon as possible after the event(s) occur. Timely in a high acuity setting is not the same as timely in a lower level of care, which includes long-term care settings. The higher the level of acuity; more entries are expected to be recorded regarding the patient care. A lower level of acuity will have fewer orders, fewer interventions, fewer interactions which equates to fewer entries representing the care rendered. The frequency of entries should be adjusted according to facility policies and level of patient acuity.

Digital Cameras – Thoughts on Buying a New One

If one has a look at the selection available, there are more than 1,500 different digital cameras available with a mind-boggling array of features and benefits, and in sizes to suit every hand and pocket possible. There are well-known brands, newer, developing brands, unknown brands… where does one start?

The simplest solution is to pick up an advertising leaflet from one of the major retailers promoting digital cameras, decide on your budget and just go and buy one. None of these retailers carry inferior products, so you will get a reasonable camera at a reasonable price and off you go…

You may well be delighted with your purchase and live happily ever after… snapping away and enjoying your pictures.

There is, however, a state of mind known as post-purchase trauma. We are all very familiar with this as in ‘I knew I should not have bought it… ‘ ‘This other one is much better value but I didn’t see it… ‘ ‘It really doesn’t have the features that I now realize I need… ‘ ‘I wish I had known… ‘ etc etc.

In the long run it is really best to try and avoid this as much as possible as it can have the effect of devaluing (in your own mind) your exciting new purchase which would be a real pity as it should be your key to a fascinating hobby.

For example, did you know that you can get cameras with what the Americans call “Zit Fix”? The camera automatically corrects any skin blemishes making this a wonderful product for teenagers. Or perhaps you really wanted to get the camera with ‘Smile Timer” – the camera will not take the picture until the main subject is smiling! Or the one with a “Blink Proof” function – the camera takes two pictures automatically and discards the one with the closed eyes!

Are functions such as these really important to you? Or would you prefer to have more control yourself? Do you want to take snapshots or do you want to add some of your own touches? As the saying goes “Do you want to take pictures or to make pictures?”

As the range of digital cameras is so large, and keeps growing daily, it is important that you think about your purchase in a careful, logical way to minimize the chances of making an expensive mistake and suffering from Post Purchase Trauma!

Each decision you take reduces the number of cameras available until you get down to a manageable number!

There are four basic styles of digital camera – the ubiquitous compact camera with a zoom range of around 4X; the so-called ‘bridge’ camera which is bigger and normally has a large zoom range – some go up to 24X; the Digital Single Lens Reflex camera (DSLR) with interchangeable lenses and lastly a number of what I term ‘new style’ cameras – mirror less, small bodies, big sensors and interchangeable lenses.

Your first, and perhaps, tentative decision to get started is deciding what you are going to buy. Go into a photo shop and look; pick up and feel each style. What suits you best in terms of size and convenience? You can then concentrate on cameras in your chosen section.

Should you decide on a compact style camera you may want to consider whether your cell phone camera will serve the purpose for your needs. This depends on your model of phone as cameras can vary considerably. It also depends on your answer to our next question…

Your next and crucial decision is: Do you want or need the creative tools for controlling Aperture and Speed? If you are planning to do anything much beyond basic ‘point and shoot’ photography you really need to be able to control these two manually. Don’t forget, photography is a fascinating hobby and, once you get into it, you may well regret not buying a camera with these creative tools. During my camera courses I often hear the comment ‘if only I had known I would have bought one of those… ‘ – it really is a crucial decision so think about it carefully! I put this ahead of the decision about budget as it may have an effect on your planned budget!

Having made this decision the number of cameras available is almost halved.

The next, obvious decision revolves around budget – it becomes the next defining cut off point in reducing your options. Be realistic and include everything – extra memory cards, spare battery, carry case etc. For your initial review it is a good idea to increase your budget slightly so that you can get a good feel for what is available.

The next step is to decide if brand is important to you – if it is, then the spread of choice is immediately reduced. A complicating factor is that the number of brands available is growing and some of the newer entrants offer excellent products – perhaps keep an open mind about this…

Continuing with our progress through the buying decision, we come to some more personal decisions which only you can make and, because nothing is easy, these may well have an effect on your original decision as to the style of camera you prefer!

How important is photo enhancement and manipulation to you? If it is extremely important you would want to go for a camera in the 10+ megapixel range (or even higher if your budget permits) and one which allows you to shoot pictures in RAW files as these contain far more digital information than the common JPEG files. This, once again will reduce your choice options as many cameras do not do this.

Will speed be important to you? By speed I mean the time taken for the camera to start up and recycle between shots coupled with the speed of the auto focus mechanism. Be sure to try each camera for yourself. DSLR cameras tend to excel in these two departments.

Do you want to use your new camera as a video camera as well as a still camera? This is fairly new technology which will again limit the number of cameras available to you. Ask the shop assistant about video quality as this too can vary.

Is a huge zoom factor important to you? The bigger the zoom factor in a built-in lens the bigger the trade off in stability and image quality – but they are convenient! They are also becoming more and more compact! Again only you can make this decision. Do you really need a big zoom? Try to be practical in terms of how much you will use it, compared with the convenience of a more compact camera body.

A crucial point is size and weight – a camera locked in the hotel safe is useless! A DSLR with a couple of lenses is cumbersome – remember that the camera you have with you is the best camera in the whole world!

Read camera reviews in magazines – there are a number of web sites such as http://www.dpreview.com which review cameras – sometimes in incredible detail but they are well worth visiting to compare models. Your camera dealer is crucial.

In the final analysis, however, it all comes down to how the camera feels in your hands… does it feel right? Are the knobs, buttons and dials placed where you feel comfortable?

What I term the ‘WOW’ factor (I am just so happy with my new camera!) is really important as a measurement of choice!

Remember, you are really the only person who can decide on what camera to buy. Make sure that you make an informed decision based on your own research. You should regards this research as part of the enjoyment of getting a new camera – you will also learn a lot about cameras!

Good luck and really enjoy your new camera!

Skin Care Reviews: Skin Care Products Containing Retinol

As you’re searching up derma affliction reviews, you ability be apprehensive what ‘Retinol’ in fact is. The commercials and advertisements accomplish it out to be a phenomenon cure, but you ability be one of those apprehensive if it comes from a nuclear bulb or an absolute plant.

Skin Affliction Reviews: Retinol and Its Roots

To put it in layman’s terms, it’s a anatomy of Vitamin A. Most humans apperceive that Vitamin A is abundant for your vision, abnormally in the dark, but they may not be acquainted that it’s aswell abundant for your skin.

Vitamin E ability be accepted for derma healing, but abounding studies actualization that vitamin A helps with your skin’s appearance.

This is why retinol is acclimated in abounding derma affliction items as abounding affirmation that arresting improvements will be fabricated with connected use. Usually, the after-effects awning beneath wrinkles, firmer derma and bigger elasticity.

Retinol is usually acquired from altered beastly forms, including fish, and is again adapted into assorted forms. The cold use is what determines whether it will be put into a chrism or a actuality that will be taken orally.

Skin Affliction Reviews: The Bulk Of Retinol Varies Greatly With Altered Products

Even admitting this one additive comes from the aforementioned place, it can be afflicted to fit all derma types. Abounding derma affliction articles on the shelves of your bounded abundance will accept a abate absorption of retinol than a decree medication will have.

If you feel a derma affliction artefact with a college absorption of retinol would be of account to you, you’ll accept to arrangement a doctor. Insurance will sometimes awning these prescriptions and the doctors visit, but you will charge to analysis that with your provider to be sure.

Your doctor will ask you a set of questions afore they appoint a derma medication absolute retinol to accomplish abiding you’re accepting the appropriate bulk but not too abundant of it to affectation any abuse to your derma or, as it is captivated into the physique through the skin, will not affectation any abuse to you at all.

With prescriptions absolute college doses of retinol you’ll charge to chase the admonition actual carefully. The abiding furnishings of these decree creams or articulate medications should be discussed with your doctor, as able-bodied as any actual ancillary furnishings that may actualization up so you’ll apperceive what to be acquainted of.

Skin Affliction Reviews: Accepted Ancillary Furnishings and Dangers

A accepted admonishing that is accustomed with all medications absolute retinol is to abstain accidental acknowledgment to the sun. It is frequently declared that you may become added acceptable to get derma blight with retinol use, so sunscreen and adumbration are something you wish to anxiously consider.

Some derma affliction reviews will aswell accompaniment that absolute sunlight will abate the aftereffect of the absolute allowances of application a retinol artefact for your skin.

For abundant women, application retinol could could cause bearing defects for the babyish as able-bodied as a college adventitious of adorning delays afterwards birth. You may accept to delay to yield this medication until afterwards the baby’s bearing and if you’re no best breastfeeding.

Depending on how anxious you and your physician are about these issues, you can allocution about which anatomy of retinol is the safest. You may in fact be directed to application an over the adverse artefact with a abate absorption of retinol.

Using derma affliction reviews will advice you actuate if you charge a derma affliction artefact with retinol and hopefully you’ll see honest reviews from humans absolution you apperceive why they absitively to use it and what their claimed acquaintance was.

There may be alone be a assertive bulk of time that you charge to accept this blazon of a medication as allotment of your derma affliction accepted and again you can change to something that is not as able and is advised to be safer. However, you ability acquisition it difficult to get a absolutely acceptable acknowledgment to this catechism after an arrangement with a dermatologist.

How Helpful is an Anti-Aging Skin Care Review?

An anti crumbling derma affliction analysis is accounting to acquaint readers about the capability of a accurate product. This analysis is mostly accounting by experts or those who address their time to the testing of assorted derma affliction articles accessible on the market. However, there are some websites out there which acquiesce an accustomed user to column their acknowledgment about the account of a derma affliction product.

These reviews are absolute useful, decidedly if you plan on affairs an anti crumbling artefact for the analysis of abortive wrinkles and added crumbling signs. Such an anti crumbling derma affliction analysis can acquaint you about the capability of assorted capacity acclimated in the authoritative of derma affliction products. Similarly, it can aswell acquaint you which capacity ability be adverse for your skin.

The internet has fabricated it absolute simple for everybody to ascertain the accurate account of an anti crumbling artefact afore spending money on it. Now reviews and feedbacks are accessible on about any derma affliction artefact you can anticipate of. There are reviews about accepted articles and even those which are not absolute accepted but still advised advantageous by abounding users.

If you are aswell searching for an anti crumbling derma affliction analysis about a artefact you can calmly acquisition it on the internet. Usually the pros and cons of a accurate artefact forth with its capacity are accustomed in these reviews. If absolute reviews are accounting by absolute users of the product, you can be assured that the artefact is in actuality acceptable and effective.

The best way to go about arcade for an anti crumbling derma affliction artefact is to shortlist a amount of acceptable articles depending on their appraisement and again award out added about their ingredients. It has been begin that the best and a lot of able articles in this class are the ones that accommodate assertive accustomed substances as their alive ingredients.

People usually allocution about these substances in their anti crumbling derma affliction review. They cover some antioxidants like vitamin A and vitamin C, retinol, cynergy TK, CoQ10, phytessence wakame and some others. All these capacity are acceptable for abiding derma bloom as they advice in the blockage of abortive wrinkles, boredom of derma and accomplished lines.

So, afore affairs a derma artefact for the analysis of the above-mentioned derma problems, don’t overlook to apprehend an anti crumbling derma affliction review. It will not alone be accessible in advertent how abundant annoyed the users are, but will aswell acquaint you about the capability of the capacity it contains.