Kardex, Medical Abbreviation, Medication Chart

KARDEX, MEDICAL ABBREVIATION, MEDICATION CHART DEFINITION KARDEX - A documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan. - Widely used, concise method of organizing and recording data about a client, making essential information quickly accessible to all health professionals involved in the client’s care. FEATURES OF KARDEM SYSTEN The following are the features of the KARDEX system 1. Concise and Comprehensive 2. Accessible 3. Organized Data Components of Kardex The following are the components of Kardex 1. 2. 3. 4. 5. 6. 7. Client Identification Medical history Current Diagnosis and Treatment Plan Medications Nursing Care Plan Daily Care Activities Progress Notes Benefits of the KARDEX system The following are the benefits of the KARDEX system 1. 2. 3. 4. Improved Communication Time efficiency Enhanced Continuity of Care Portability What information is included on the KARDEX A KARDEX is essentially a care plan chart or template that’s uniquely used by and for nurses. Because of this, nurses should have ownership of the information that is added or removed. The information that a nurse chooses to organize on a kardex will depend on the type of facility they work in and their patients assignments. Here are some common pieces of information that are included on a kardex. What information is included on the KARDEX 1. 2. 3. 4. 5. 6. 7. Patient code status Diagnoses and Allergies Diet and ADL requirements IV sites and daily labs Scheduled medications Recommended care tasks Family contact information OBJECTIVES OF GOOD DOCUMENTATION AND REPORTING GUIDELINES 1. 2. 3. 4. 5. Enhanced Communication Improve Patient Safety Support Clinical Decision – Making Ensure legal Compliance Facilitate Quality Improvement Principles of Good Documentation and Reporting The achieve these objectives, the following principles should be adhered to: 1. Fact – information about clients and their care must be factual. 2. Accuracy – information must be accurate so that health team members have confidence in it. 3. Completeness – the information within a record or a report should be complete. 4. Currentness – ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following:  Vital signs Benefits of the KARDEX system     Preparation of diagnostic tests or surgery Change in status Admission, transfer, discharge or death of a client Treatment for a sudden change in status 5. Clarity – use clear and concise language, avoiding jargon and abbreviations that may be misunderstood 6. Legibility – ensure that handwritten notes are legible and that electronic records are formatted consistently 7. Organization – the nurse communicates in a logical format or order 8. Confidentiality – a confidential communication is information given by one person to another with trust and confidence that 10 Tips on How Nurses Can Improve Documentation One of the task that a nurse must accomplish for every shift is their documentation of the patient’s care. This is considered a legal document that can be used in every court of law. 1. 2. 3. 4. 5. Objective is the key Mind the time Legible is credible Never too late to be accurate Allergies are priorities 10 Tips on How Nurses Can Improve Documentation 6. 7. 8. 9. 10. Heads up for your abbreviations No to erasures Think of your ink Be a follower, not a false leader If it’s not yours, do not share Benefits of the KARDEX system The following are the benefits of the KARDEX system 1. 2. 3. 4. Improved Communication Time efficiency Enhanced Continuity of Care Portability Medical Abbreviations Example: A patient is receiving 1 mg TID. How many mg will they receive in one day? Remember: TID = 3 X a day Answer: if they are receiving 1 mg for 3 x a day . That’s 1 mg x 3 = 3 mg per day. Medication Abbreviations 1. Medical prescription are written direction for the preparation and administration of specific medication or treatment. Prescriptions specify a drug or therapy name, dose, form, delivery route, frequency, timing and purpose. Additionally, they tell the pharmacist how much to dispense and how many refills are available. Times of medications Administration