Charting
     The process of recording vital information 
      that is communicated to others.
       – Facts and figures that are specific, clear and 
        precise
       – Contains correct language, medical terms and 
        abbreviations
       – Observations, interventions and communications
       – Reports to authorities as child or elder abuse
    Charting
    Assessment of quality and effectiveness of 
      nursing care
    Permanent record
    Assessment of quality and effectiveness of 
      nursing care 
    Legal Document in the event of litigation or 
      prosecution
    If not charted, legally it was not done
    Charting
    Legal Requirements
      -regulated by state laws
      -professional standards
      -Joint Commission on Accreditation of Health Care 
        Organizations [JCAHO]
     Charting Specifics
      Black ball point pen because it microfilms best
      Errors are corrected by drawing a single line through 
      the error. Above write “Mistaken Entry” [ME] and 
      your initial.
      No white-out, erasers, eradicators, covering-up 
      materials
      Error no longer written.  Juries associate it with an 
      actual nursing mistake
       Charting Specifics
       Each entry is signed with your first initial, last 
         name and status
                   J. Smith, SN
                   R. Jones, RN
                   Script not printing is used for the 
                     signature and it should appear at the 
                     right hand margin of the narrative 
                     note.