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Janma Gurung

English 2010

Semester Project

Part One

Intro

Medical charting is a legal paper work, which is one of the most

important thing in the medical field. Everyone working in the medical field

are required to do medical charting because there are lot of benefits of

medical charting. Such as, it will help doctors to prove that the treatment

was carried out properly, helping analyze the treatment results, plan

treatment protocols and many more. Every person working in the medical

field will have documented everything they do for the patient in the

computer.

Purpose

There are many purpose of medical charting. Such as having proof of

what the care has been given, giving, or need to give. There is a saying if

you didnt chart it, it did not happen.

Also, government require to do medical charting because, it is a medical field

and lot of incidents happens. Doctors are able to save many peoples but not

everyone. When that happens family member might deny that and blame

the doctors. I am not saying that doctors dont make mistakes. All I am

saying is, if they didnt make a mistake and the treatment went as it is

supposing to be, it will be the legal documentation that will save the doctors
carrier and life. If you charted the wrong thing and the nurse happen to give

the wrong dosage of medicine, you just put the patient life in danger or even

kill them. A simple mistake in medical field can take someones life.

The other purpose of charting is we will be able to access the file

anytime when we need and even able to look at the history of patient. Every

time doctor do any kind of treatment, they will look at your medical history.

Not only yours but your family history also because lot of genetic disease has

been inheriting by your ancestors. So, when we document things, it will be

easier for us in the future.

Context:

The context that we use in medical charting are:

Patient identification
Physical examination
Treatment that is given and are still in process.
To teach client.
Discharge plan and process after that.
Operative procedures.
Evidence of nurse care or treatment.
Medical history and medical diagnosis.

Writer/Reader

Writer and reader are everyone who is working in the medical field.

For example: CNA, does most of the daily bases activates. They chart

everything they do into the computers with date and time. Once they do this,

nurse checks it. The nurse checks it whenever they get time. They check it

very often. In this case CNA is the writer and Nurse is the reader. Second part
comes the Nurse role. The most important part of nurse is they do procedure

call head to toe assessment. Nurse charts all the things and after that

doctors see it. Here, Nurse become the writer and Doctor becomes the

reader.

Conventions:

The convention of this genre should be well organized that is required

for profession. Formal, which means no bad words, correct spelling, clear to

understand, and especially know medical abbreviations. Medical abbreviation

is very important and which I came to know when I was taking CNA class in

high school. Anyone who goes into medical field are required to know the

medical abbreviation because if they dont know about it, then it will be very

difficult to communicate and understand the other medical people. Every

time doctor, nurse, or CNA, leaves a note they will have medical abbreviation

in. It will take longer time to write all the words so they use short cut to

communicate and save time. Anytime we leave note to nurse or doctor, it is

important to know that never use slang words in. It is not appropriate and

not accepted at all.

The picture posted below is medical abbreviation.


Part Two

I began my research by looking at some of the websites that my

professor sent me. On those websites I had almost everything I need to know

about the nursing charting. There was why the nursing charting was done,

who the audience will be, and style. The only part I wasnt sure was, who

does what part? Everyone in medical field have their own responsibility from

CNA through Doctor. So, first I interview one of the CNA from the hospital I

work in. She works at the bone marrow transplant department. She said she

does most of the daily bases activities. Such as checking blood pressure,

respiration, heart rate, pain, weight, Temperature, oxygen, and bed sores.

They check the patients weight 3 to 4 times a day, depending on the patient.
As soon as they are free or they are done with the daily bases activities, they

charted it immediately. If the CNA sees abnormal while doing vitals, they

immediately alert the nurse.

Second person I interview was a Register Nurse. She told me that,

nurses also do the intake and output fluid, patient response to the medicine,

and paint. Most important thing they do is head to toe assessment. The

picture I posted below shows the head to toe assessment. She said that

they chart all these things and after that doctors see it. If the nurse sees

anything abnormal, they directly go and talk to doctor. They chart everything

but most of the time they dont wait for doctor to see it. They will just go up

to doctor and say everting to doctor.


Well I was interviewing the nurse, I came to know that only doctor

prescripts the medicine. Not even Nurse have the authority to prescripts any

kind of medicine to patients. Nurses only gives the medicine that has been

prescript by doctor. She also said that they chart all the medication they

give. They also chart PRN, which means as per needed medication such as

nausea, pain, also the response to the medicine also. They ask questions of

what kind of pain are they in or ask to describe their pain. Did the pain come

quickly or slow, or where the pain is and if it radiates it anywhere? They also

chart dressing change.

Reference

Steckdale, Agnes, personal interview. 04/24/2017. CNA

Gold, Connie, personal interview. 04/24/2017. Nurse

"Information about Writing Expectations in Nursing." Untitled Document.

N.p., n.d. Web. 28 Apr. 2017.

Morales, Katie. "17 Tips to Improve Your Nursing Documentation."

NurseTogether.com. N.p., 25 Oct. 2012. Web. 28 Apr. 2017.

Thomas, Joseph. "Medical Records and Issues in Negligence." Indian Journal

of Urology : IJU : Journal of the Urological Society of India. Medknow

Publications, 2009. Web. 28 Apr. 2017.

Part 3

Here I did an example of a patient who is sick and have an abnormal

vitals.

Date: 12/12/12
Name: Aggarwal Kajal N/A
Last Frist Middle
Patients:
CNA
Vitals: Normal Vitals:
o Blood pressure: 140/98 90/60 to 120/80
o Pulse rate: 80/120 60/100
o Respiration:20/26 12/18
o Pain: 9/10
o Weight: 90 pound Depends on the age and
height
o Temperature: 105F 98.6 F
o Oxygen: 102 millimeter of mercury
o Sores: sores everywhere
o Vomiting: 3 times with in 1 hour
Purpose:

The purpose of taking the vitals is to see the progress of health. We

can compare the vitals from the previous time and see how much good or

worse has the health been. Through the vitals we can also see what

medicines does the patient need to take and take care of diet also. Since the

patient have low weight, dietitian will give more nutritional and protein food.

This will also help doctor prescript medicine for patient or show nurse what

medicines does the patient need to take.

Writer/reader

The first step to medical field is CNA so I will be taking these vitals as a

CNA. The vitals that I took was very abnormal and that is very unusual to

have. The nurse will see it once I document that in the computer. I am the

writer and the nurse is the reader. Sometimes there comes a point were you

need to talk to nurse rather than communicate through computer just like in
this case. The patient needs and immediate treatment. So, I will be going up

to nurse and telling her about the patient situation. I will be the speaker and

she will be the listener.

Convention:

The convention of nursing charting will be written as: Patient is very

unwell. Need immediate care. BP high. In high of pain. Low Weight. High

fever. Pules rate, respiration, and oxygen are abnormal.

It will be written short but very clearly. Short because doctors and

nurses are very busy taking care of the patient and they dont have so much

time to read a long long thing that can be explain in two words. Clear

because what is the use of it if the doctors cant read what you have written.

So, writing clearly is very important.