What is the proper approach to charting in patient care?

Proper Approach to Charting in Patient Care

The patient chart must contain time-based documentation of all medications (name, route, site, time, dosage/kg, and patient effect), vital signs monitoring (heart rate, blood pressure, respiratory rate, oxygen saturation, and when applicable, expired CO2), level of consciousness assessments, adverse events with their treatments, and discharge condition with confirmation that predetermined discharge criteria were met. 1

Core Documentation Requirements During Treatment

Medication Administration Documentation

• Document every medication with seven critical elements: name, route, site of administration, exact time given, dosage per kilogram, and observed patient effect 1
• Calculate and verify mg/kg dosing before administration, with special attention to obese patients where ideal body weight (not actual weight) should guide most drug calculations 1
• For obese patients specifically, use adjusted body weight (ABW = IBW + 0.4 × [TBW - IBW]) rather than total body weight to prevent relative overdose 2

Vital Signs and Monitoring Parameters

• Record at minimum: heart rate, blood pressure, respiratory rate, and oxygen saturation at the time of treatment and at appropriate intervals during recovery 1
• Include expired carbon dioxide values when monitoring sedated patients 1
• Continue documenting vital signs until the patient meets predetermined discharge criteria 1
• Consider using validated sedation scoring systems to standardize documentation of level of consciousness 1, 3

Pre-Procedure Documentation Requirements

• Perform and document a "time out" before any procedure to confirm patient name, procedure to be performed, and laterality/site 1
• For hospitalized patients, write a note documenting that the chart was reviewed, positive findings were noted, and a management plan was formulated 1
• If emergency conditions preclude complete pre-procedure information, obtain and document this health evaluation as soon as feasible 1

Post-Treatment Documentation

Discharge Documentation

• Document three essential elements at discharge: the exact time, the patient's condition, and confirmation that level of consciousness and oxygen saturation in room air have returned to safe levels by recognized criteria 1
• For patients receiving supplemental oxygen before the procedure, document similar oxygen needs after the procedure 1
• Note that some sedation medications have long half-lives with risk of re-sedation, which may necessitate documenting extended observation periods 1
• A practical discharge criterion is the infant or child's ability to remain awake for at least 20 minutes when placed in a quiet environment 1

Adverse Event Documentation

• All adverse events and their treatments must be documented 1
• This includes desaturation episodes, airway interventions (jaw thrust, positive pressure ventilation), prolonged sedation, unintended use of reversal agents, and unplanned hospital admissions 1

Common Pitfalls and How to Avoid Them

Dosing Calculation Errors

• Never assume visual appearance excludes obesity—always obtain measured weight for patients who appear obese, are over 60 years old, or have significant comorbidities 2
• Do not use total body weight for drug dosing in obese patients, as this dramatically increases overdose risk and respiratory depression potential 2

Incomplete Time-Based Records

• The chart must contain a time-based record, not just a summary of events 1
• Each entry requires documentation of when it occurred, not just that it occurred 1

Missing Pre-Procedure Safety Steps

• Failure to document the "time out" before procedures represents both a safety and documentation failure 1
• For hospitalized patients, even when the hospital record contains adequate presedation health information, a note must still be written documenting chart review and management plan 1

Special Populations Requiring Enhanced Documentation

High-Risk Patients

• For children with severe obstructive sleep apnea who have experienced repeated desaturation episodes, document the rationale for lower titrated doses due to altered mu receptors and increased complication risk 1, 3
• Former preterm infants younger than 60 weeks postconceptional age require documentation of prolonged observation due to increased apnea risk 4

Quality Improvement Integration

• Consider tracking documentation completeness as a quality indicator, such as percentage of patients with complete time-based medication records or complete vital sign documentation at predetermined intervals 1
• Chart audits can identify documentation gaps, with reliability checks showing that 5% random re-audits should demonstrate at least 84% overall agreement 1