The Art of Charting

What is Charting?Charting is vital for several reasons.

• It is the basis for communication between all healthcare professionals who care for the resident.

• Doctors, Nurses, Social Services, RD’s and support staff use it to create a specific level of care provided for the resident for optimum results.

• It is also a tool used to decide among various treatment options, to determine level of reimbursement for nursing services, and to determine the effectiveness

of interventions provided.

The resident’s physical, mental, social and spiritual conditionis demonstrated through complete documentation.

Charting is?A legal medical record that can be used in

the court of law.

The main mechanism by which state surveyors, attorneys, and the attorney’s experts will evaluate the quality of care

provided by the nursing home

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Charting Rules 101

#1 If it’s not charted it’s not done.

#2 Always chart the problem then the solution.

Pit Falls of Charting

Diets don’t match upOn tray ticket, notes and

Computer application

Sloppy hand writing

Too little information

Using previous notes for assessments

Actual Charting

• “Patient was alive but without permission.”

• “Resident is eating less than 25% but has a good appetite.”

• “Patient had waffles for breakfast and anorexia for lunch.”

• “Resident is alert but could not speak to her because she was asleep”

• “Healthy-appearing, decrepit 69-year-old male, mentally alert but forgetful.”

• “Patient was alert and unresponsive.”

• “The patient gets hives from contrasts, strawberries and shrimps and also

two of her children.”

• “Resident has issues and bouts of craziness ”

• “Patient eats death threats for breakfast.”

• “Resident has issues”

Significant Nutritional Changes and Conditions that fail to get documented• Significant appetite changes• Weight change triggers

• Residents complaints of oral pain, chewing or swallowing problems (Procedure to chart)• Significant edema in resident fluctuating weights up and down drastically

• Lack of any wound supplements• Food allergies not documented• Changes in food preferences

• No mention of dialysis treatments• Decrease in tube feeding consumption

• Mental status• Diarrhea

• Needs to be fed• ADL eating utensils and drinking cups

• Denture and oral status• Correct diet and liquid status

• Residents receive poor quality of care• Supporting staff don’t see the whole nutritional picture of the resident• Insufficient nutritional care provided• Residents could die, nursing facilities sued, court proceeding ensue, fines implemented,

loss of facility reputation, money and jobs

TYPES OF CHARTINGInitial 5 day Admit note14 day note, 30, 60, 90, Significant Changes

(Change of therapy, Weight, Hospice care, Palliative Care, Feeder)

Quarterly noteAnnual note

Being discharged to the hospitalBeing re-admittedOral Status change

Eating behavior change, ADL devices addedObservation notesResident expired

The 7 Day Story

Initial Nutritional Assessment

Resident___________________________________ Admit Date__________________ Age__________

Diet Order: __________________________Primary Diagnosis________________________________

Physical Characteristics: Sex:___ M___F Ht:________in. Wt_____LBS. IBW Range_______ IBW: Below__ Above__

Phys. Observation: Week___ Edema +_____ Wounds_______ Paralysis____ Amputation______

Dental: Own Teeth? ____Yes ____No: Broken___ Missing ____Likely Cavities_____ No Teeth___

Denture Status: Full Set____ Yes___ No/ Upper____ Lower____/Partial: Yes___ NO____/____Upper ____Lower

Will not wear dentures _______ Wears dentures at times ________ Wears to eat only_______

Food Consistency: Puree____ Mech. Soft____ Reg.____ Chopped____ Ground Meats____ Finger Foods____

Liquid consistency: Regular Thin____ Nectar Thick____ Honey Thick____ Pudding Thick _____

Ability to Feed: No Assist _____ Set-up Assist _____ Fed by staff____ Monitored by staff____

Assist Devices: Divider plate____ Weighted utensil___ ADL Cup____ Curved utensil_____

Other: ____________________________________________________________________

Chewing/Swallowing

Chewing Problems: ____ NO_____ Yes: Pain____ Irritation____ Ulcers____

Swallowing Problems: ____NO ____ Yes: Pain____ Difficult y____ Coughing____ Gagging____

Mental Observations: Confused______ Combative______ Non Responsive ______ Alert____ Disoriented______

Ambulation: Independent____ With Assist____ Wheel Chair____ Wheel Chair Pedal____ No Ambulation___

Food Preferences/Intolerances

Location of meals: ____Dining Room ____ Room

Food Likes: ____________________________________________________________________________________

Food Dislikes:__________________________________________________________________________________

Food Intolerances/ Allergies: _____________________________________________________________________

Comments:____________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

Interviewed By: ____________________________________ ___________________Date:____________________

Physicians OrdersOrderDate6

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Start Date

OrderType

Order No.

IntervalCode

Time Code

Orders

12/22/16 12/22/16 Med 31 QD QHS J30.9 Allergic rhinitis. Singulair 10 MG tablet po Q HS Generic Montelukast Sodium

3/03/17 3/04/17 MED 72 QD QHS E87.6 hypokalemia Potassium CL 20 meq. tab. Give 2 tabs PO qday

6/25/18 6/26/18 MED 155 QD QD8 Vit. Deficiency, Vit D3 1,000 unit tab. 1 tab qday

4/5/17 4/5/17 DTY 146 QD TIDW/M

Nas; Extra gravy w/meals

5/15/17 5/15/17 MED 212 QD QHs Remeron 7.5 mg QHS D/T depression.

3/18/18 3/18/18 SUP 146 QD TIDW/M

House supplement 4oz. PO TID with meals

12/22/16 12/22/16 MED 23 QD QHS Flomax 0.4 capsule PO Q HS

12/22/16 12/22/16 MED 28 QD QHS Latanoprost 0.005% eye drops 1 GTT in each eye Q HS

8/03/18 8/03/18 MED 161 PRN EPRN Flu vaccine 0.5 ml IM Q Fall When available

7/12/16 7/12/16 MED 53 QD QHS Lasix 40 mg. D/T Edema QHS

7/5/18 7/5/18 MED 21 QD BID Cranberry 450 MG TAB BID

2/14/16 2/14/16 MED 122 PRN EPRN Tylenol 200 mg. TAB AS Needed for pain

12/22/16 12/22/16 MED 26 QD BID84 Colace 100MG Capsule. 1 capsule PO Q HS for Constipation

3/18/18 3/18/18 SUP 145 QD QD7 4 oz. Prune juice PO with Breakfast

12/22/16 12/22/106 MED 28 QD QHS Flomax 0.4 MG capsule PO Q HS D/T Retention of Urine

FACTS OF THE STORYOrientation

DietTextureLiquids

SupplementsWound supplements

Oral statusChewing, Swallowing or Mouth pain

Admit weight or Current weightEating percentage and eating habits

VitaminsDiuretics

Appetite Supplements Any proactive care measures

Vital Lab DataLikes and Dislikes

Story Note FormatIntroduction

Basic Facts

Care Plan

Conclusion

The IntroductionBeing that the reader does not know

anything about the resident yet. Your note shouldtell the reader who the resident is in general, to get to

know themEx: Is the resident alert and can they answer basic questions.

Are they friendly, talkative something about them that defines them and sticks out

Basic Facts of the ResidentWeight, height, diet, liquids, eating habits,

Vitamins, diuretics, where they eat, do they feed themselves,Oral status, PO %, supplements, stimulants, ADL’s etc.

Care Plan• Significant weight loss/gain action• Oral concerns addressed• Eating habits being qued, monitored etc.• Preferences noted and implemented• Dislikes noted and implemented• Diminished PO addressed with snacks,

alternate foods, supplements • ADL needs activated• Decreased hydration addressed• RD education implemented

What will my department do to

address any issues noted from the

Facts

How often will the precautions be done

What are the goals; if any do you have

for the residents nutritional needs.

Rules to Oral Charting1. Always physically go see a resident and check on their oral status

2. Never go by previous notes of other staff workers

3. If the resident is not responsive then ask the CNA or Nurse to help you

determine if they have any teeth, dentures, partials and if they have

any discomfort or pain during meals.

4. At an assessment if you ask a resident if they have any pain, chewing or

swallowing problems; and they say yes,

You must first: Tell the Nurse so they can verify

Then the Social Service director so they can also verify

Do not chart anything until you find out what is being done.

5. The SS director will investigate with the LPN and check the validity of the statement of

the resident then determine if the resident needs a dental appointment.

6. Once the SS director speaks with the resident, nurse, ST or CNA; she may make an

appointment with the dentist. At that point you can make a note in the chart that

the resident has an appointment to see a dentist on what ever date.

7. Once the resident has come back from the dental appointment the SS director should

give you the paper work which states the results of what action was taken to address

the resident oral issue.

8. You should then chart about what action as taken to address the resident oral issue.

Resident - Mary Butterfluffanutter• Non-responsive

• On a NAS Pureed diet with Nectar thickened liquids• Gets HI Call 4 oz. TID and Mighty Shakes BID at snack pass

• Started on Remeron QID recently• Allergic to shellfish

• Takes Liqua Cell BID for Wound healing• Has own teeth with upper partial and missing teeth

• No Chewing swallowing or mouth pain• Height 62 inches, 112lbs.

• Current weight is 112 lbs. and has had a significant weight loss of 6 lbs.in 30 days• On weekly weights

• Eats 25% to 50% of meals and snacks • Refuses some meals

• Has to be qued for optimum PO and eats in the restorative dining room• Takes a MVI + Minerals and VIT C for wound healing Qday

• Likes oatmeal dislikes cabbage and brussels spouts

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