ppt课件-the anesthesia chart（麻醉图）.pptVIP

“The White Card” This is sent to the billing office; most important to have everything legible and correct! It’d better be right!!! “Weren’t you told to write legibly on the white cards?” AANH torture chamber I wrote down the wrong diagnosis—what’d you do? Do not use the following abbreviations: or 1.0 (do not use trailing zero) .5 (do not omit a zero before a decimal point) U or μg (write out “units” or mcg for micrograms) MgSO4 (write out magnesium sulfate) Mso4 or MS (write out morphine) cc (use ml) These and others are found at the bottom of HSR Progress notes and on the hospital web site Major problems associated with charting Failure to document emergence Failure to date, time and sign entries Failure to document positioning Failure to tally drugs, fluids, output Use of unapproved abbreviations (use of pre-printed entries is best) Unexplained entries (should provide a rationale as to why a medication was given if not obvious) Illegibility Incompleteness (errors of omission) Other problem areas associated with charting… Mechanical ventilation Antibiotic administration (particularly pre-incision timing) Provider changeovers 7 TEFRA requirements Unexplained gaps Inclusion of pt ID and time outs Erasures, gaps, and alterations to the record (these raise inferences of errors, inattention, and falsification of data) Remember: Write legibly; check spelling Black ink may be mandatory in some institutions Blue ink now thought to be OK; easily delineates the original record from a copy Document events briefly but comprehensively Cross out errors with a single line and write “error” next to it; add your initials Do not go back and add to or alter the original chart Additions may be made in the progress notes Add up totals (meds, fluids) at the end of the case and record them Pay attention to detail Always use labels Write N/A through areas that are not used DON’T FORGET TO STAMP OUT; write in the end time if you are off of the floor (in OB, the unit, Specials, M