Focus Charting

Nurses New Nurse

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imanedrn

547 Posts

Specializes in ED/trauma.

Wow, after reading everyone's posts, I am SO thankful to be at a hospital that uses computerized exception charting. I can add notes to each "exception" area. For example, if I say the pt's cardiovascular system is NOT normal, it goes into a bunch of fields that prompt you for information: heart rate, pulses, edema - most anything you can think of. Anything else, you can add in the "comment" box at the end. I've been told that, as a new grad, I actually chart TOO much. For example, I'll include the pt's tele box # in the comment section or include "no complaints or additional problems noted." All of that makes life MUCH easier to chart on my patients - esp. when we reassess. It sounds like the ways you all mentioned (that I learned in school and never used much outside of clinical reports...) are great for making you actually think like a nurse (I feel like I'm taking the easy way out!), but it also sounds very cumbersome. :nurse:

seyd

15 Posts

Your job would be much easier if u would prefer using NANDA. because all that you need about making chart is right there. you just have to know what to prioritize when making a diagnosis. hope this helps

Specializes in surgery.

hi!! i just want to inquire from you guys. it is possible that Narrative charting and focus charting can be recorded simultaneously. and if that practice has been done already; can somebody please tell me what specific term are they using in that particular documentation?!! thank you very much. i am having my research on this particular topic.:typing i was tasked to bring a report on that matter. :nuke::nuke::nurse: God Speed!!

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