This section is designed to help with some charting issues we have seen. Rood and Dereck are in charge of chart QA's and have seen some trends.
Common Charting Errors:
Chart Q15 min vitals: pt is stable.
Chart @Q5 min vitals: when pt is unstable
AND when pt is receiving medications that alter BP or HR.
(we have not been doing this)
ETCO2: We have had a couple of charts that do not have ETCO2 charted or capnography on strips. We need to place and chart ETCO2 monitoring on every pt given sedation and analgesic meds even if given prior to your arrival.
Mag Sulfate: Chart DTR's Q15 min.
Charting
As always, let me know if there is anyhting that I could to be doing better. Thanks.
What I have recently learned!
Dereck and I (and now Clint and I) had a nighmare patient which translated to a nighmarte chart. I learned so much from the audit of this chart from Craig/Tosha/Mike/Odie.
I submitted the Chart for those guys to review and they tore the chart apart! Actually, they were fairly gentle. But they did scrutinize every single thing. Here is what I learned:
Do NOT double document! If you charted something outside of the Event Log then it does NOT have to be included in the Event Log. Example: Do not document ANY medications in the Event Log. Do not chart that you intubated the pt in the event log. These are both charted elsewhere.
When charting "pt assessment performed with universal precautions in place." use the "PPE" tab in the Event Log. This is a billing issue.
When documenting meds given by your crew, always use the comment box and explain why you are giving the medication. Even if it is obvious.
If you have a 'missed' blood pressure and still have the rest of the vitals then don't chart the location of cuff and "automated cuff". Leave those blank.
Always document FiO2 as a decimal (1.0 = 100%). Even though Golden Hour shows a % still document as a decimal. You need to chart FiO2 even if the pt is being bagged (1.0).
Chart how tidal volume was determined. Chart this in a Vital Signs Vetilator section comments or in an Event Log.
Always ask either Craig I., Tosha W., Mike S., Cole R., or Odie about anything you are uncertain of. If you want you can click Begin Audit Process and they can look over the chart. DO NOT click Final Audit until the chart is reviewed. Hope some of this helps. Let me know if you have any tips, tricks or suggestions. Thanks!
