[Daytonite]

Found this website today. Might be of some help to people:

http://www.childbirths.com/euniversity/documentation.htm - Documentation. A resource for nursing students on e-University. Some nice concise information here about what and what not to chart. Talks briefly about POMR (Problem Oriented Medical Record), SOMR (Source Oriented Medical Record), Narrative Charting, ADPIE, PIE, Focus charting, SOAP and SOAP(IER) charting, CBE (charting by exception), flow sheets and check lists, reporting and taping reports (do's and don't's) and the essentials of taking verbal orders from doctors.

[Rondoletti]

There's a book: Taylor's Clinical nursing skills (i think that's the title) which gives you examples on how to document procedures since it gives you the procedures step-by-step (with rationales) and also it's recent (published 2006 me thinks) I find it's really helpful.

[Nurse`Chief~Chickie]

I made mysself a checklist during clinicals that i printed off and took each day. That way I would practice writing out my notes after assessments without prompting/help. Then I got out the list and checked over what I had or hadn't included. Over the course of the year, I went from NI on charting(lots) to getting compliments on my notes. This way you get used to the flow from what you observed, but have a failsafe.
Last noc, I wrote a book on 1 of my pts who I'm pretty concerned about FVD-wise, the nurse I had taken over for wrote 2 notes, 3 lines each. (forgot to sign 1 too) and had nothing to judge my call to the doc on(change-wise) but what happened after 1900. Point being, no way to know if the things I observed were acute changes or not, as the taped report wasn't oriented to that info, and I didn't get a f/u with her.
Your charting IS important, I'm glad they drilled it into me the way they did.
Happy Charting!

[petraa]

BP 165/60, HR 70.
Temperature 36,5.
No pains.
Food tastes.
In a good mood.
Wants to go to home. // PetraK

[Daytonite]

Here are two sites where you can get specific instructions on what SOAP notes are, what kinds of information go into a SOAP note and one site has sample SOAP notes that you can view.

http://www.medicalassistant.net/soap_note.htm - Writing SOAP notes. Includes links to sample SOAP notes at the bottom of the page.

http://en.wikipedia.org/wiki/SOAP_note - SOAP note

[grannypatches]

I am a lpn nursing student. Today at school all of us were told that if we get 2 U's on our nurses notes and care plans that despite our grades we are out of the program. I freaked out. This is second semester and its hard. We are cramming 16 weeks into ten. I am maintaing good grades but my nurses notes are the worse. Can anyone direct me to good websites showing good examples of how narrative nursing notes should be. I have searched to no avail. I am sending for the book "charting made easy" but it will not arrive for a while. I was so upset when I came home I fell across the bed exhausted and nearly in tears. I have worked so hard in school and 2 U's can end it all. I already have 1 U. Any good advice for a stressed out struggling LPN student?

[aaa rn]

Hi Grannypatches...WoW, I can't believe how archiac some nursing programs are. I've worked two sites that expected narrative charting. One employer expected us nurses to use DAIR charting, The other, SOAIP charting--both have similarities.
D = DATA. What did you hear and what do you know to be true (empirical evidence garnered thru the five senses and known facts).
A = ASSESSMENT. So, as a nurse, what did you think of the above data?
I = INTERVENTION. So, what did you do about the situation?
R = RESPONSE. How did your patient respond to your intervention?

S = SUBJECTIVE: what did the patient say?
O = OBJECTIVE: What are the known facts and what is the empirical info?
A= ASSESSMENT: See Above
I = INTERVENTION; See Above
P= Plan: What is the next step?

Using the two templates, for expample, the narrative would read something like this:

Mary Smith c/o HA. States she has tried to relax but the headache is getting worse.
Mary Smith grimaces as she talks. MAR with PRN Tylenol Q 6 hrs- HA.
Mary Smith has had a HA x 2hrs, could benefit from prn Tylenol.
Provide pt with 500 mg Tylenol.
Response: Effective or Plan: F/u with Tylenol results in half hour, contact attending if no relief.

Granted, this scenario is simplistic, but I hope it helps. Good luck.

[Daytonite]

grannypatches. . .most large facilities have a policy and nursing procedure that defines exactly how they want the nurses to document the care they give. The next time you are in your clinicals and have a chance, ask about the charting policy and to see the policy and procedure manual on this (it may be computerized these days). Sometimes the nurse educator of the facility will have this information as well and may even have a self-learning packet they give to orientees (new nurse employees) that they would be willing to give you to help you out with learning this.

From Portable RN: The All-in-One Nursing Reference, 3rd edition, by Lippincott, Williams & Wilkins, page 674. . ."Narrative charting is a straightforward chronological account of the patient's status, the nursing interventions performed, and the patient's response to those interventions. Documentation is usually included in the progress notes and is supplemented by flow sheets. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards require all health care facilities to set policies on how frequently patients should be assessed. Document patient assessments as often as your institution requires and more frequently when you observe any of the following:

• change in the patient's condition
• patient's response to a treatment or medication
• lack of improvement in the patient's condition
• patient's or family member's response to teaching

Document exactly what you hear, observe, inspect, do , or teach. Include as much specific, descriptive information as possible. Always document how your patient responds to care, treatments, and medications and his progress toward the desired outcome. Also include notification to the physician for changes that have occurred. Document this communication, the physician's response, new orders that are followed, and the patient's response.

You can organize your notes by using a head-to-toe approach or by referring to the care plan and documenting the patient's progress in relation to the plan and any unresolved problems. Regardless of the way you organize your narrative note, be specific and document chronologically, recording exact times."

This sample of narrative charting is given on page 675 (kind of hard to show the actual physical formatting, but I think you're more interested in the actual wording, right?):

"11/26/06 2255 Patient 4 hr postop; awakens easily, oriented x 3 but groggy, incision site in front of L ear extending down and around the ear and into neck--approximately 6" in length--without dressing. No swelling or bleeding, bluish discoloration below L ear noted, sutures intact. Jackson-Pratt drain in L neck below ear with 20 mL bloody drainage measured. Drain remains secured in place with suture and anchored to L anterior chest wall with tape. Pt. denied pain but stated she felt nauseated and promptly vomited 100 mL or clear fluid. Pt. attempted to get OOB to ambulate to bathroom with assistance, but felt dizzy upon standing. Assisted to lie down in bed. Voided 200 mL clear, yellow urine in bedpan. Pt. encouraged to deep breathe and cough qhr, and turn frequently in bed. Lungs sound clear bilaterally. Antiembolism stockings applied to both lower extremities. Explanations given regarding these preventive measures. Pt. verbalized understanding.----Bridget Smith, RN

2300 Pt. continues to feel nauseated. Compazine 1 mg IV.----Bridget Smith, RN

2335 Pt. states she's no longer nauseated. No further vomiting. Rating pain in incisional areas as 7/10, on a scale of 0 to 10. Medicated with morphine 2 mg IV.----Bridget Smith, RN

2355 Pt. states pain as 1/10. Demonstrated taking deep breaths and coughing effectively.----Bridget Smith, RN"

Lynda Juall Carpenito has this to say about narrative charting:

"Progress notes should contain. . .unusual events or responses, or significant observations or interactions. . .a good rule to follow whenever information comes to the attention of the nurse, which if known by the attending physician would cause the physician to write new medical orders or to cancel or elaborate on existing orders or to discontinue orders, is to verbally communicate the information to the physician. In addition, the nurse should record the information and the notification of the physician in the progress notes. For example, if the results of a neurovascular assessment were. . .abnormal, the nurse would record. . .it [in] an. . .explanatory progress note." (Nursing Care Plans & Documentation: Nursing Diagnoses and Collaborative Problems, 3rd edition, pages 28-29)

Now, I realize that as an LPN, you won't necessarily be responsible for notifying doctors if you work in an acute hospital setting, BUT if you work in LTC as a charge nurse you will, so you need to know this information.

Hope you find that helpful. When I was working I used to make sure I had copied all the doctors orders for labs, diet and treatment onto my "brains" (report sheet). When I charted, I generally started out by writing my head to toe physical assessment of the patient followed by attention to the various doctors orders and how they were being carried out. As I got more experienced I was able to include some of that with the physical assessment as I was writing it up. I always charted observation of IV sites, any tubes or drains and the amount and color of what was draining out of them, dressings or incisions and the amount and color of any drainage, if the patient was getting oxygen, the patients activity (walking, ambulated with one or two assistants, being turned, sitting up in a chair, had no movement on one side of the body as in stroke patients, sleeping) and how they were accomplishing their toileting. Any major problems that you know the patient to have should be addressed as factually as you can write them. And, factuality is usually the challenge of documentation. Some words just include our own bias and we have to be careful of that. You will find that over time you will develop a regular way of charting, a format of your own, that you won't deviate that much from. This is a career long evolution. You can also download and use the Student Clinical Report Sheet for one patient that is attached at the end of this post to help you with organizing a head to toe assessment.

Here are some sites where there are other samples of narrative charting and other information about nursing documentation:

• 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://allnurses.com/forums/f205/examples-charting-138835.html examples of charting for students and links to other examples
• http://medi-smart.com/documentation.htm - Do's and Don'ts of Nursing Documentation
• 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

[Daytonite]

Originally Posted by grannypatches

Thank you for your very helpful suggestions. It will help me a lot. I have been hearing that narrative charting is not used much anymore but our program requires it. Thanks so much your help...

I know that depending on where you work many are likely to work with check off sheets and do charting by exception. These forms were developed as time saving strategies for nurses. However, if you do chart with those kinds of forms there is usually still a place for a narrative note. No matter how extensive these check off forms are, they can't include everything. There are always going to be instances of things that are going to need to be narratively written--ALWAYS. Not to instill any fear in people, but I've attended a lot of legal seminars for nurses and one thing that was always stressed is to keep in the back of your mind the idea that if you ever have to sit on a witness stand what you are putting on that form, or fail to put on it, is preserved forever and tells what you observed (or didn't observe) and did (or didn't do) for that patient. A year from today you won't remember the details, but what you put in the chart will still be there to tell the story for you. Thoroughness will never do you wrong. When I worked with check off forms, as I went down the form and realized there was something I needed to expand about in one particular section, I stopped and went immediately to the narrative section and did some narrative charting before returning back to where I left off on the check off part of the form. If I ever remembered something that I had forgotten to chart I made a late entry.

[VickyRN]

Here is a head-to-toe narrative charting template that I developed for my first semester RN students last semester:

2/12/2007 0800. 86 y.o. male admitted 2/1/07 for left CVA. VS 37.4° C, HR 97, RR 22, BP 140/76. Alert and oriented x 4; denies any pain or distress. PERRLA. Responds appropriately to verbal stimuli; no slurring of speech. At risk for aspiration related to dysphagia; on thickened dysphagia diet. Feeds self with assistance. Skin acyanotic with loose turgor. Mucous membranes moist and pink. Negative JVD. Respirations even, unlabored. Breath sounds clear to auscultation throughout all lung fields. (If your patient is on O2, make sure you record the O2 rate and delivery system here, along with pulse ox readings). Apical pulse regular rate and rhythm; S1, S2 noted. Abdomen soft & nondistended with bowel sounds active in all 4 quadrants. Pink nailbeds with capillary refill less than 2 seconds in all extremities. Peripheral pulses palpable in all extremities. Moves all extremities. Hand grips unequal: strong on right, weak on left. Left arm has limited mobility due to weakness secondary to CVA. Has a 20 gauge saline lock to right forearm. Site is free from redness or drainage, with Tegaderm dressing intact. (If your patient has an infusing IV, make sure you record the fluid and rate in your assessment). Uses urinal, has occasional episodes of incontinence. Urine clear yellow. No skin breakdown noted. TED hose on bilaterally. Homan’s sign negative bilaterally. Feet cool, dry, intact, with thick toenails bilaterally. Side rails up x 3, bed in low position. Call bell within easy reach of right hand. Instructed to call for any needs or to request assistance before attempting to get up. Verbalized understanding. Side rails up X 3. Will continue to monitor closely………………………… S.Johnson, SN, *****