Examples of Charting

I come from an era of nursing where nursing notes were nothing but narrative charting, no check off sheets for us! Anyway, what I did over my career to make sure I didn't forget anything (we had to narratively write out our head to toe assessments every shift) was to make up a sheet of all the areas to remember to hit. I got the idea from one hospital I worked that had a laminated sheet at the front of the nurses notes section of every chart. It basically was a list of a head to toe assessment and included a short description within each body system to address in our charting. I added things to mine, such as to pay particular attention to IVs and IV sites, restraints, bed rails (up or down), out of whack labwork, did I call the doctor, and things like that which I found probably needed to be addressed in my charting in order to CYA.

If I were you, I would get a blank copy of the check off assessment done at one of your clinical areas. Use that to start creating your own little charting list. Create the list in a Word document that you can save as a file on your computer. That way you can easily access it and make changes to it, as it will be an evolving work. It's easy enough to print one out.

I had a special sheet I made years ago for assessing, treating and charting on chest pain. I did it because I was working on a cardiac unit and we had a lot of people who got chest pain and I was always forgetting something to ask the patient or to chart. So, I sat down and went through my textbooks as well as the hospital protocol for chest pain and made up this sheet which I had to type on a manual typewriter (this was before computers). I covered it with clear contact paper to protect it and carried it on my clipboard. When a patient had chest pain I would put that sheet out and refer to it while I was at the bedside with the patient. I often would sit with the bottle of Nitroglycerin in my hand, give the patient a NTG tablet, take his blood pressure and ask him about whether his pain was improving or not. I also knew, from my list, to watch for SOB and cyanosis. I would write down the times I was giving the NTG to the patient (our protocol was one tablet every 5 minutes up to 3 tablets until pain was gone). When I sat down to chart, all I had to do was follow my cheat sheet. I had all the times I had given the NTG and the patient's responses to my questions.

Insofar as the actual wording of your charting. . .keep it factual, keep it simple. Here's how I used to do mine (what I can remember of a normal one): Alert and oriented to person, place and time. Skin pink, warm and dry. Repirations regular and unlabored. (Or, crackles ascultated in RLL with deep breath--productive coughing of green colored sputum upon deep inspiration) No cough noted. Continuous O2 at 2L/min by nasal cannula. Abdomen rounded and soft with active bowel sounds ausculated in all four abdominal quadrants. No pain to mild palpation of abdomen. (Or, no bowel sounds auscultated in any quadrant of abdomen after one full minute of listening at each quadrant.) Foley catheter patent with clear yellow urine draining. IV intact and patent in anterior aspect of left lower forearm with 1000cc D5W infusing at 100cc/hr by gravity drip (we didn't use pumps in those days, but if we did I always mentioned that a pump was in use). No pain, redness, or swelling at or above IV site. No calf tenderness. No pedal edema. Knee high TED hose in place bilaterally. Side rails up. Call light in reach. This is just a sampling as I was remembering things. Mostly, you tend to write the same old stuff all the time. It gets interesting when something isn't normal and you have to describe it.

Hope this helps you.

Lippincott publishes a book entitled, "Charting Made Incredibly Easy." It can be purchased at any major bookstore in America since it is such a common book for nursing students and newer nurses. Additionally, it can be purchased online at Amazon.com, Ebay.com, and at any number of internet bookstores.

The best compliment I ever got on my charting was when a surgeon told me he could see the patient when he read my notes. That's one of the main purposes of charting, communication to someone who wasn't there when you were.