Question about charting

[androrn]

I can't believe it is time to head to camp. I'm leaving on Friday to head to the wonderful state of Maine. In the meantime, I have talked to one of our newer camp docs and she had some questions concerning documentation. Let me explain that I have been at this camp for most of 14 years and last summer was the first one I had to miss---and the doc's first year there. We are at a residential boys camp with about 250 boys.

We currently document in a log book why the person came in and what was done (basically a full note) and then that info gets transcribed to each indivuals chart. Lots of writing and double charting. Our director likes it that way so we can make copies of the log book each morning for her to see. What I'm wondering about is if we can get by with documenting the basics in the log book and have a separate form for each visit to attach in the chart. I know the ACA standards and they have always seemed a bit vague on this point--other than to indicate that a log must be kept and the type it must be, not really what has to be included. Just trying to cut down on the time spent writing as well as a way to easily read each chart since our docs change every one to two weeks.

Thanks for any info anyone has--and sorry this was a little lengthy. Hope everyone has a great summer. I can't wait to get to camp and see my boys again.

Happy camping,

Androrn

[BonnieSc]

Yes, you can just write the basics in the log book, but be careful that it doesn't look like you're "omitting" information from the "official" logbook--all the important details must be there. I don't keep individual charts (my girls don't usually stay longer than a week), but I do send notes home to the parents detailing their health care, and these notes are usually quite different from my nurse's notes--layperson's terms, in some cases more details.

Think about the PURPOSE of each chart and let that guide what you do with it--for me, at least, the primary purpose of the main logbook is for continuity of care--so that anyone else who cares for the camper who's come in again can see what I did previously and either continue with that or change it, as needed. For you, since you keep detailed individual chart, someone else providing care would see the short note in the main logbook and look up the details in the individual chart. I think that system should work well.