[jackel]

I'm looking for helps in charting. I'm a NEW nurse and I work in a very active ED, But we do not have a tri-fold or computer to help jog my memory in the areas I need to chart, Its just a blank flow sheet to start you off. Please does anyone have a sample charting or guides to help with better charting. Thanks Jackel

[aquaphoneRN]

Ah, I'm so glad this subject came up. I'm in a similar situation. I'm also a rather new nurse (less than 2 years) and work in the ED. I was pondering the same dilemma at work just today.

My ED also doesn't have "check-off", "tri-fold", or any other type of assessment tool.

Our assessment tool is a blank piece of 8.5" x 11" ruled carbon paper.

Keep in mind this is a major New York City hospital! We're in the dark ages in NYC!

Anyway, if you read most of the literature on what constitutes proper documentation, the general rule is, honestly, that you're supposed to chart everything, and I do mean everything.

However, in a busy ED this is not realistic. In fact, it's quite impossible. Often you can't dedicate more than 5 - 7 minutes to charting, if that, so please people, I beg you, give REALISTIC advice, not textbook advice!

I've been trying to focus on just the chief complaint(s), my actions, doctors actions, and responses.

Example: 47 y.o. male comes in with chest pain:

Received pt @ 10am, A + O x 3, c/o mid-sternal CP 8/10 started "this AM" about 4 hours ago, non-radiating. No SOB. No Palpitations. EKG done, reviewed by MD whoever, pt. placed on monitor, o2 2L NC, HL # 18 R AC, cardiac set drawn and sent. Bedside troponin negative. Seen by MD whoever. NAD. aquaphoneRN RN. ---------------------------------

I would probably attach a strip from the monitor at the bottom of the page.

So there, it's short, it doesn't read like a complete history, and it doesn't tell you much about what the patient doesn't have, for example, I didn't say "no headache" or "no dizziness" or "no blurry vision", but if I have to list everything the patient doesn't have and their complete history, I'll be there all day. It DOES list every intervention I've taken, that the MD is aware, and what complaints/s+s the patient DOES have.

If a lawyer wants to argue that I didn't write "pt. has no headache" I can always argue, I didn't white it because it wasn't there.

If you have no tools and no computers, you have to be short, to the point, focus on the chief complaint and list your interventions and doctors awareness. Anything more is totally uinrealistic in my opinion.

Hope that helps. Look forward to hearing from other ED nurse on this, whether or not you agree, your perspective is welcomed and appreciated.

[candyndel]

Always, always, always do a head-toe at the beginning of your shift (and I dont mean on the new ankle that just got here an hour ago...) then prn. Especially if you have the 'hold' problem that we do (usually about 20 every morning with over half for ICU or CCU)!
You'll be surprised at what you might find that's different than in the report you got...but you also might see a red herring or two!!

Remember (among other things) you are getting paid to assess/monitor the patient and report changes in assessment. You arent charting to verify how your day was spent....I can not believe my eyes when I have to review a chart that looks like this:
700a Rec'd report
715a ECG done
720a NTG 1/150 given SL.
725a #18g to Left AC. labs sent.
730a ASA 325mg po given.
740a PCXR done.
750a ECG repeated
755a Plavix 300mg po given. Cardiology fellow at bedside.
AHHHHHHHHHHHHH!!!!!!!!!!!!
Those activitites all have their place in the record, but a scribe could do this!

I also suggest reading the notes of the shift(s) before you. That always helped me to learn what to look for and how to say it.
Good luck- once you have it down- your probably go to EMRs anyway

[aquaphoneRN]

[quote=candyndel]Always, always, always do a head-toe at the beginning of your shift (and I dont mean on the new ankle that just got here an hour ago...) then prn. Especially if you have the 'hold' problem that we do (usually about 20 every morning with over half for ICU or CCU)!
You'll be surprised at what you might find that's different than in the report you got...but you also might see a red herring or two!!

This is really good advice, and I try to do this, but I just don't have time to document it all. In my ED we don't have EKG techs, we don't have nurse's aides or ED techs the majority of the time. We don't have IV start kits. We often don't have working BP cuffs/monitors. We don't have computerized documentation.

I feel like I just don't have time to document everything I should, so that's why I just do a more fucused assessment. Of course, the sicker the pt. the more I will try to document.

Documentation, to me, is perhaps the hardest part of nursing. There is a constant fear of omission, yet I don't have time for inclusion.

[susi_q]

Typical charting in our ER ...
**symptoms related to chief complaint.
**assessments with subsequent interventions.
**I ALWAYS note when i take over the care of a patient ("care assumed") and do my own assessment (noting any changes from prior), then if there is a problem that started before it got there, i've done what i could to cover my a**.

a lot can be said in a few words if you concentrate on why you are doing what you are doing.

[Jen2]

Received pt @ 10am, A + O x 3, c/o mid-sternal CP 8/10 started "this AM" about 4 hours ago, non-radiating. No SOB. No Palpitations. EKG done, reviewed by MD whoever, pt. placed on monitor, o2 2L NC, HL # 18 R AC, cardiac set drawn and sent. Bedside troponin negative. Seen by MD whoever. NAD. aquaphoneRN RN. ---------------------------------

I do this also but I add an ABC + Neuro assessment + focus assessment

I usually start out with my focus assessment, then move on to neuro and ABC's.

1300: Pt brought to room 15 cc: midsternal chest pain 5/10 started "around noon" non-radiating no relieving factors aggravated by deep breathing, unrelieved by NTG x's 3 at home, - N/V. Cardiac monitor applied displays NSR in the 70's , O2 at 2l/min via nasal canula initiated. #18 gauge in LAC x's 1 attempt pt. tolerated well, labs drawn and sent, EKG and CXR at bedside. Dr. so and so aware and at bedside evaluating.

Then as I am labeling and sending my labs and the Dr. is assessing and the EKG and CXR is being performed I will go in and add.

1310: Pt. A&O x's 3 follows commands and appropriate. PERRL 3mm and brisk, hand grips strong = bilateraly. RR 20 shallow non-labored lungs CTA, O2 sat 98% on 2L via NC skin warm/dry/pink. NSR remains on monitor HR in 70's pulses +2 X's 4. Rates midsternal chest pain 3/10.

I will then document any changes through out the patients stay or just chart assessment remains unchanged.

[aquaphoneRN]

Originally Posted by Jen2

I do this also but I add an ABC + Neuro assessment + focus assessment

I usually start out with my focus assessment, then move on to neuro and ABC's.

I will then document any changes through out the patients stay or just chart assessment remains unchanged.

Hmm . . . I my opinion, your example represents very, very good charting. So in your ER, are you also lacking computers and essentially using a blank sheet of paper to chart?

[angelique777]

I was having the same problem. I am in nyc and do have a check list and we also document some things on the computer. I was still having trouble with my nursing notes. Wanted to be sure I covered all the areas in proper order. So I purchased Nursing Documentation Handbook. I keep it in my bag. It has a good chart that list the syetems in order and when I admit a patient I just use that list to make sure I did not miss anything. It gives you an idea how to chart but in a nice concise form it fits all on one sheet once I copied it. It serves as a nice cheat sheet in my pocket. I made a copy of the chart from the handbook and keep with me. If I want specific things to look for based on certain conditions the handbook has more information based on patient condition .,

Nursing Documentation Handbook third edition by TM Marrelli there are other books but I got this one cause of size. If your in New York ........Barnes and Nobles on 18th street has a great nursing section and you can find other nursing documention helpers that you can browse and see if they are suited to your needs the handbook was helpful to me. It has a sample of a checklist as well. Since your facility does not have one.

By the way what hospital do you work at in NYC. I do not find my facility antiquated was curious where did you work that it was like this.

Any way Good luck in the ER I still waiting to hear from the ER in my facility so I can start work there. I am in ICCU right now .

Wish you the best
Angela

[loricatus]

Originally Posted by angelique777

Nursing Documentation Handbook third edition by TM Marrelli

Do you know the ISBN number of the book? What you have done sounds like a great idea. Thanks

[purplemania]

talk to your Education Dept. about the need for documentation that is simple: things you can fill in the blank or circle. Then talk to Risk Management about how hard it is to document. These are two depts that are very interested in your dilemma. There is probably a documentation committee but they will need input from the experienced ED nurses to make changes. Creating new forms is cheaper than defending yourself in court. Meanwhile, make a list of what is supposed to be on the chart and when. Type it up when you get home and go to Kinko's to get it laminated (unless you have one of those machines. A lot of scrapbookers do). Carry the guide with you. Sometimes seasoned staff forget what it is like for newbies.