lpope's blog

Charting

Charting Over the last few weeks we have been discussing nutrient analysis. In dietetics it is important to be able to analyze a patient’s diet or analyze a recipe or look at nutrient content of specific foods. These tools are useful as we counsel patients on their diet. If the past, we have talked about ways to gather data from patients. We can use a diary filled out by the patient or interview the patient to ask about what they eat over the last 24 hours. Remember the importance of following good interview techniques. You have a computer project assigned, where you are interviewing a family member or class mate regarding their diet and then you are entering this information into a computer program to complete the nutritional analysis. For our discussion today, let’s assume that we are working in a hospital or nursing home and have been to visit a patient. During our visit we obtained a lot of information as well as a 24 hour recall regarding their diet. Let’s focus on what we will do with this information. Let’s talk briefly about a patient’s chart. It is important to remember that at chart is a legal document. Anything that you write in the chart can be pulled into a court of law. Since malpractice is so rampant, be careful what you write. Most charts are divided into sections for each of the disciplines. You will have a section for the physician notes, a section for the nursing notes, a section for the labs, etc. Dietary has a section where notes about the patient will be written as well. Other things that are important regarding charts include: Make sure you have the right chart Read other sections so you don’t have to ask duplicate questions. Write legibly, concise, clear notes reflecting facts Always chart in ink Don’t erase – if you make a mistake, draw a line through it and initial it. Don’t wait until the end of the day to chart, do it after the visit Don’t document what others have said or done. Don’t chart saying you have done something when you have not Accurately chart what your patient has told you, not what you assume they are Saying. Many charts are kept chronologically. If you don’t get an entry into the chart and are out of chronological order indicate out of order in the chart and initial. Many facilities due to legal requirements will not let you physically write in the chart because you are a student. In this case, you can practice writing a chart note on a piece of paper which your supervisor will check and help you perfect if needed. In dietetics most of our charting currently is using an anacronym called SOAP. S stands for Subjective O stands for Objective A stands for Assessment P stands for Plan It is important that you know what each letter in the acronym stands for. As you review your powerpoints on charting you will see examples of what can be placed in each area. Remember you are there to obtain factual information about your patient. S stands for subjective. If I give you a subjective questions on a test, it is asking you to answer the questions in your own words, similar to a discussion question. When I grade the question, I know what I am looking for, so if you list the points you will get credit for the question. I might give you three out of 5 points because it is subjective. Things that would be subjective in the chart are: Things that the patient says – I like green beans I don’t eat breakfast I hate milk The patient maybe stated that they were on a particular diet before coming to the hospital The patient told you that they have lost 10 pounds over the last two weeks Maybe the patient has food allergies, or can’t eat certain foods. These are things that may be important to your assessment, but aren’t documented by you, so you put them in the subjective area. When we see them in the subjective section, we know that they have not been documented. O stands for objective If I give you an objective test, it would mean that there is a set answer to the question. Often multiple choice questions are objective. They are factual. Many things are included in this section of our note. For example: The patients height and weight. If this was obtained by a hospital personnel, it can be put in the objective section. If they patient tells you their weight it is Subjective. The diagnosis of the patient Diet prescription for the patient. Maybe IBW or BMI of the patient Lab values that will be pertainent for your assessment. The patients medications Diet history taken Instructional material given or discussed What you actually do with a patient

Posted at 03:43PM Oct 25, 2006 by lpope in General  |