Charting do's and don'ts - page 2

I would like to know what are the correct way to chart in the nursing notes when describing a pt. the do's and the don'ts. Anybody know!!!!... Read More

  1. by   Myxel67
    Use professional, clinical language. I once read a nurse's note stating, "Pt has thunder thighs."
  2. by   Myxel67
    Quote from RNsRWe
    I had a disagreement with a charge nurse recently; I was going over student notes and found "pt seemed tired" or "appeared tired" or something like that, and I commented on it. She told me that the student was right, etc etc, it was objective data....this was NOT correct IMO, not according to everything I had learned (and much more recently than she; perhaps when SHE was in school, where she went to school, it was different). At any rate, it IS a no-no to chart what they "appeared" to be; chart what they ARE!




    Actually, this will vary depending on where you are, and the facility that you're in, and their policies too. I was in one hospital where x4 was a restraint, but the one I'm in now does it routinely, NOT a restraint. And it's not like anyone is messing up, it's a hospital-wide policy that has been seen by TPTB.

    I had no clue before going to school what the big deal about charting was, LOL...figured you just jotted down their vitals and what the doc said, right? ROFL...
    I believe it is JCAHO that has determined that 4 side rails are a restraint, and here in FL we must follow JCAHO rulls if we want to keep our accreditation.

    In nursing school and at work we are continually told, "If it wasn't charted, it wasn't done." However, from my observation over the past 13 years, the fact that an action was charted does not always mean it was actually done. This is a sad state of affairs.
  3. by   deb123
    Do hospitals give new nurses info during orientation regarding special things to chart and not chart? I learned how to chart in school, but the posts regarding the side rails up x4 are making me wonder.
  4. by   RNsRWe
    Quote from deb123
    Do hospitals give new nurses info during orientation regarding special things to chart and not chart? I learned how to chart in school, but the posts regarding the side rails up x4 are making me wonder.
    We didn't have that in our orientation, except to drill it home to us to never chart that an incident report was completed/filed. Beyond that, they assumed we learned in school how to chart, I think.

    Frankly, I have never, ever seen a single nurse's note that had anything to do with how many siderails were up! If a patient is in restraints, that would be charted, of course. And we will also chart "fall precautions maintained" if applicable; if you have a somewhat confused patient that needs rails up and a bed alarm activated in order to know he isn't slipping out of bed, it's charted like that. But no, I've never seen anyone actually write "siderails up x4" or "all rails up". Unless you read the student notes
  5. by   nursejllrn
    Every facility I have worked at in 18 years charts how may side rails are up (usually two) even the ones with computer charting had a slot to check for it. Must be a state thing??? Or old habits die hard!!
  6. by   NotReady4PrimeTime
    Our shift assessment form has a section on safety, which includes "siderails: up? down?". Of course in PICU they aren't considered restraints in the conventional sense, but rather safety precautions. We are continually reminding parents to put the siderails up before they walk away from the bedside. Even sedated kids can take a tumble. We have a separate section to document the use of limb restraints, which are routinely used on our population, and our flowsheet has a column for documenting the continued use and assessment of limb restraints hourly.
  7. by   scrubsnhugsRN
    I have been making it a habit to read the nurses notes from prior shifts and taking note of how they are documenting, Nurses notes were covered in school but we were using a different type of note than where I presently work so I had to essentially start all over again. I had this very discussion with a more experienced nurse just this week, my notes tend to be long winded noting all that I have been doing over a 12 hour shift..but I am learning my notes can be smaller since much I am documenting is on other paperwork (flowsheets for assesments etc). We use the PIER notes.
  8. by   RNKay31
    That is a very good topic, also in my facility we were told to not write found pt lying on floor, but to write Pt was noted, cheers to this topic
  9. by   truern
    My first nursing note on a patient for the day usually goes something like this:

    0730 POD #2. Received pt resting quietly in bed s/complaint. A&OX3. VSS. NSR per monitor. 02 at 2L via NC. O2 sat 92%. Encouraged C/DB. #22 LAC infusing NS @ 75 ml/hr. IV site WNL. Midline abd incision s/redness, edema, tenderness, or drainage and open to air. JP LUQ patent and draining sml amt serosanguinous fluid. Bed in low position w/callbell in reach. Bed alarm on. SRX2. Terri Rue, RN

    We initial boxes for pt checks q 2 hours unless there's a reason to assess more often. Then at 1600 I do another head to toe assessment and may chart something like this:

    1600 Pt OOB to chair. Denies pain, SOB. A&OX3. VSS. O2 sat 93%. NSR per monitor. No changes. Will continue to monitor. TRue, RN

    If at 1700 he complains of incisional pain, for example, then I'd document this:

    1700 Pt c/o midline abd incisional pain 8/10. Morphine 2 mg IV given. Pt returned to bed and positioned for comfort. TRue, RN

    At 1800 this may be my documentation:

    1800 Pt states "pain is much better." and is now 3/10. No further intervention at this time. TRue, RN
    Last edit by truern on Feb 9, '07
  10. by   truern
    Quote from RNsRWe
    Frankly, I have never, ever seen a single nurse's note that had anything to do with how many siderails were up! And we will also chart "fall precautions maintained" if applicable; if you have a somewhat confused patient that needs rails up and a bed alarm activated in order to know he isn't slipping out of bed, it's charted like that. But no, I've never seen anyone actually write "siderails up x4" or "all rails up". Unless you read the student notes
    Must be a day shift thingie

    Our noc shift follows the care plan and addresses each of the pxs identified in their first note...thereafter they only chart by exception or occurances. Us day people tend to chart more for some reason LOL

    Oh, and if I don't have an order for all rails up then I usually chart SRX4 per pt request because in our facility all rails up IS a restraint. Some patients just plain want them all up. I've also had a really tall patient that hated the bed in low position....up it went and I charted it was at his request.
  11. by   RNsRWe
    Quote from truern
    Must be a day shift thingie

    Our noc shift follows the care plan and addresses each of the pxs identified in their first note...thereafter they only chart by exception or occurances. Us day people tend to chart more for some reason LOL

    Oh, and if I don't have an order for all rails up then I usually chart SRX4 per pt request because in our facility all rails up IS a restraint. Some patients just plain want them all up. I've also had a really tall patient that hated the bed in low position....up it went and I charted it was at his request.
    Well, I guess the answer is, "it depends"! Funny what we notice about the others' shifts; since as a night person I'm always charting after the day person's notes, it's THOSE notes I've never seen any mention of the siderails in. And, of course, if I look through to the previous nights, ours as well.

    I notice some nurses chart much more than others, but I can't generalize night vs day on our unit....sometimes I see nothing more than a single line filled out in addition to the checkoff forms and sometimes I see practically a novel. And that's for all the shifts. I remember a mention being made of hardly any notes from some of the day shifters, and the answer was "we don't have TIME to chart as much as you night people, we're too busy" :angryfire Glad I got that secondhand, or I probably would have gone postal on her butt!

    As for me, since I know we are supposed to chart by variance, I fill out the forms very completely, adding notes to them as I go, and then don't have a ton to write in the variances. My carecharts have most of the details, if not all of them, by the time I'm done.

    Probably the part I hate most of nursing: charting!

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