I Am Lost...Charting Concerns

  1. So, here is the deal:

    We have the pt chart, that has progress note sheets for the Dr. The sheet is split in half and one side is for orders and the other is for notes. The chart contains a nursing notes section but there are only the admission history sheets and no other pages to be able to chart things.We also have a body system-based report sheet that we use to let the next shift nurse know what is going on. We also have an assessment sheet that we do everyday each shift.

    My question is this: Where do I make my notes and what do I make note of?

    I have looked through the nursing notes and it contains pages from the original assessment but no blank sheets to report anything.

    I write things on my report sheet but should I be putting this info somewhere else? This gets thrown away after 24 hrs. When the other nurses speak of charting, they say they are talking about the assessment sheet.

    For instance,

    Pt c/o of n/v. I give her Zofran after verifying new order from the DR. I report this on my report sheet. Should I also make a note details beside the DR.'s order in the note side of the progress note? When I gave it, how the pt reacted after, etc.

    I take my pt off of her IV. I d/c the fluid in our IV assessment on the computer but should I also be reporting it beside the DR.'s note??

    I really don't see notes made like this. I am lost. Can anyone help me understand?
  2. 3 Comments

  3. by   Purple_Scrubs
    I have been out of the hospital for a while, but I cannot stand an unanswered post, so here goes!

    Med times and d/c times might be documented on the MAR and no where else. I have seen this before. One place I worked had an electronic MAR and there was a place you could put notes, such as your assessment data. Could this be where nurses are documenting the med times and related notes?

    Also, do you have a preceptor? If so, don't be afraid to speak up and ask for clarification!
  4. by   NewRN2008
    you need to find out what your hospital policy for charting is. is it charting by exception or ? that is first of all. as for where you should chart, you can go back and look at what others have done to get an idea of what you should be really doing. and i agree with above poster, that you have to have someone to have someone to go to to ask, IE: a preceptor or mentor. and if you dont, you need to ASK, speak up, before you mess up, or end up having to go to court and rely on your charting to remember something and then cant because your charting isnt up to par. ( not to try and freak you out, but that is a fact of life and a huge part of charting too) you need to use your charting to track pt's and how their stay is going, to make sure you are tracking what is changing or what is going wrong.

    gl! Speak up!!!
  5. by   MB37
    ASK someone at work! A preceptor or mentor, or a clinician or charge. Every hospital has a different system, and ours is very clear about what they want. I, for example, typically do not write a note if I give zofran for c/o nausea if it was already listed on the PRN MAR, because I wrote that I gave it on the MAR and the indication was nausea. I do write a note if I call a physician re: a new problem (new onset nausea) and receive a one time or PRN order for the same Zofran. Same with pain - I medicate per the PRNs if I have them, only write a note if pain is uncontrolled by meds already ordered and I have to call to try and get something new. We're supposed to use a certain type of charting (DAR, whereas the docs use SOAP) and they spot check us periodically. We had more than a few lectures on good, legal charting in orientation - I'm surprised that you didn't. Someone should be happy to help you out with your hospital's policy.