|Nurse updating chart|
One of the main duties of a nurse in a medical facility is charting. From the minute you meet a patient you begin writing, asking questions, filling out forms. After about an hour or so you have become well acquainted with the patient, his past medical history, his family's medical history, and current problems. Some people become quite aggravated with this process, others enjoy it. It is the job of the nurse to make it as painless as possible.
My father recently went to a doctor in a building that houses several doctors’ offices. He went in, filled out several sheets of paper, giving them every bit of information including his shoe size and favorite color (not really. he just felt that way). Immediately after he had finished he was sent to a physical therapist in another office a few doors down. When he entered the office, he was handed another stack of forms to fill out asking the same information. Well...needless to say my father refused to spend more time answering the same questions and told them to either get a copy from the other Doctor, or he was going home.
HIPPA laws require that nobody has access to your medical records but you and your physician, unless you give permission of course. The best way to handle a situation like this is simply to interview the patient. This will put the patient at ease, allow for one to one contact, and depending on penmanship, will allow you to read the information as well.
When I began taking care of my husband, I stopped charting, didn't feel the need. I mean, it was just him and me, and I was taking care of him every day. There was nobody to report to. It was not like there was another shift coming, or doctor's rounds. But then, my husband had to be deposed for his worker's compensation case. The lawyer for the company he worked for wanted specific information, such as dates and actions, which I of course couldn't provide. That day I went to the store, got a notebook and some page separators and started a medical chart on my husband, because I didn't want to be caught with my britches down again.
The first page of my chart was like a front page of a hospital chart. It listed his Name, Social Security number, address, phone number, insurance information, doctor's name and address, next of kin, known allergies and immunizations. The next section listed his medications. It included the name of the drug, strength of the drug, number of times to take it, and since he had multiple doctors, I included who prescribed the drug. I also had several copies so that each time he was transported to the hospital or doctor; I could simply pull a sheet and have all the information available, especially in emergency situations.
The next section included a list of supplies. It listed the name of the supply, the company that manufactured it, and the order number. I added a column to that page later listing the date ordered and received when we were switched to a different provider, and we had problems getting orders in.
Next was a section on Doctor visits and hospitalizations. It included the name of the doctor, date, reason for the visit, and outcome of the visit.
Since my husband was incontinent, and used a catheter, the next section was for input and output. For this section I printed out a calendar for the month. I would put the total for each day, on the day of the month it occurred. Now you are probably wondering, how could she possibly remember everything for the whole day to write it on the calendar? Well...I printed out a weekly calendar and placed it on the refrigerator. Every time I got a drink, I would simply write it on that day. At the end of the day, I totaled it all up. Since my husband's urine was measured in cc's I converted the fluids he drank into cc's as well. This is not as hard as it sounds. For my husband, he drank sprites in a can. I poured them into a large plastic cup with a cap and straw so he wouldn’t dump them in the bed. 1 can drink is 350 cc's (this information is on the can). I made a chart from 1 to 6 cans, and what the total would be. That way, I wouldn't have to be doing a lot of adding. 1 cup is 250 cc's, and if you drink something that is bottled it will tell you what the amount is. Milliliters and cc's are the same thing. I would also put a check mark on the days he had a bowel movement, if there was more than one, I would just put a check mark for each one. This is good for making sure there is no constipation or impaction.
The last section in my "chart" is for notes. I will talk more about that next time. I don’t want to overload you with too much information. So I will let you digest this and see you again soon.