[leeniebeanie_2767]

I am an LPN student who is starting acute care on Tuesday. After doing vitals, assesing, documenting, we are left on out on our own to take care of the patient all day. I have no clue how to chart properly, and after reading care plans, what should I do? We as students have no one to follow for info but can track down an instructor who would not be very happy. I do not want to bother the head nurse for every detail on various patients, but am overwhelmed to be given this much responsibility after doing long-term care- where we had a CNA to show us what they do for patients. The instructor said we cannot make mistakes in charting. Any advise on how to find ways to chart correctly, and what to do for a patient after vitals and assessments are done? I would appreciate any advise so I don't go into the hospital looking like a scared kitten. Thank you for this website!

[sister--*]

Read your pt.'s chart. See how the others are charting. Address your pt.'s diagnosis, condition, and goals. Facilities can differ on just how to do it. Remember, though, that your charting is your pt.'s day and it is a legal document. It reflects not only your pt., but YOUR assessment and care. If something isn't charted the courts consider it unaddressed and not done. Be concise yet thorough.

As far as what to do for your pt. I have no doubt that you'll find many things that need addressing. An LPN in an acute setting does not work alone. You'll have a primary or charge nurse to help direct your care. They are your contact people for direction and support. Utilize them.

I hope you find your day busy, interesting, and a very valuable learning experience.

Welcome to clinicals!

[Daytonite]

Normally, before or after report you should check the Kardex or whatever mechanism the facility has in place that keeps a listing of the patient's current physicians orders. This will include medications, treatments and tests. These are things that need to be done for the patient and have to be worked into your time with them. In some cases treatments will be done by ancillary departments such as physical therapy or respiratory therapy. Other times the nurse is responsible for getting things get done. In any case, the nurse is ultimately responsible for making sure that all is being managed.

Once you have done the care for the patient, it is a good idea to take your patient's chart, go through it completely and take down some notes (particularly if you are going to be doing a care plan or case study on the patient). Look at the doctor's orders from the patient's date of admission to the current day. Read all the doctor's progress notes since this will tell you what the medical plan of treatment is if the doctor is a good documenter. You should also read through the lab tests, x-rays and any assessments that were done by other healthcare providers. This is all part of the assessment process and is going to help you get a better understanding of what your patient is experiencing and going through. By doing this with all your patients it is also going to help you get a better understanding of medical treatment of the various conditions.

If you run out of things to do, ask the staff nurses if there are any procedures you can observe or something you can help with. Remember to follow your instructor's instructions when it comes to administering medications or performing any treatments, however, as they are your immediate supervisors and responsible for what you do.

Basically, you document what you've done for the patient and what your assessment of the patient was. Each facility has its charting rules. Here are some links to other threads on documentation that you might find helpful:

http://allnurses.com/forums/f205/examples-charting-138835.html

http://www-isu.indstate.edu/mary/chart.htm - this is a sample of how to do a narrative charting of a head to toe assessment. It is for a patient with a recent CVA.

http://www.nursingcenter.com/prodev/ce_article.asp?tid=622257 - Ladies & gentleman of the jury, I present. . .the nursing documentation. A CE article from Nursing 2006 on advice when charting patient care that may help you sidestep a lawsuit or be well prepared to defend yourself in court if you have to.

https://nursing.advanceweb.com/Common/CE/Content.aspx?CourseID=251&CreditID=1&CC=36532&sid= 1095 - Documentation: Avoid the pitfalls of improper documentation practices. An article from Advance for Nurses

[rags]

Thank you Daytonite! I came to this discussion hoping to offer my help and in turn found some valuable information that I can use myself. What wonderful sites!

rags