[VickyRN]

Another example of narrative charting, this time with multiple sequential entries:

EXAMPLE: Pt with tracheostomy on the rehab unit.

0700 – Assumed care of pt after reporting on the primary nurse. Received pt in bed, resting quietly with eyes closed. Easily aroused to alert and fully oriented state with voice. Client indicates by shaking head that presently he has no needs and no pain or distress. Respirations even, unlabored via tracheostomy. Pt is receiving humidified oxygen @ 28%, 6 liters, via trach collar. SaO2 97% on continuous pulse oximetry. Trach site is midline and patent, and trach collar is secure to site. Breath sounds are course, with diminished air flow @ bases anteriorly and posteriorly. Suction, ambu bag, and oxygen set-up are at bedside. Pt HOB is mid Fowler’s. Instructed to call for any needs; pt verbalized understanding. Call bell within reach, SR up X 3, bed low position with wheels locked. Will continue to monitor closely.

0730 – FSBS 280 per glucometer # 4. 6 units Novolog insulin administered subcutaneously under supervision of instructor @ left upper outer arm. Pt tolerated well. SaO2 98%.

0820 – Eating 1800 calorie ADA breakfast (no fluid restrictions) without any signs or symptoms of aspiration. Feeding self; indicates he needs no assistance. Scheduled medications administered without difficulty. SaO2 96%.

0900 – Pt given Percocet 5/325 mg oral dose per request, in anticipation of scheduled occupational and physical therapy. SaO2 97%.

0915 – OT in room with patient. Pt indicates that he is tolerating therapy well. SaO2 98%.

1000 – Pt denies pain. Rates pain 0/10. Physical therapy at bedside. Pt taken off unit via wheelchair with portable O2.

1100 – Back to room; indicates he tolerated physical therapy well. Denies pain. Hooked back up to humidified oxygen 28% 6 liters, SaO2 98-99%. Tracheostomy care performed under supervision of instructor. Inner cannula changed out. Site without erythema or discharge. Skin intact. Patient tolerated well. Pt denies need for suctioning at present time. Only small amount of thick yellow mucous noted, which patient adequately coughs up.

1130 – FSBS 205 per glucometer # 4. 4 units Novolog insulin administered subcutaneously @ right upper outer arm, under supervision of instructor. Pt tolerated well. Denies any needs. SaO2 98%.

1200 – Sitting up in chair. Eating lunch in no acute distress. No changes noted from earlier assessment. Trach remains midline, patent, and intact. Humidified oxygen 28% 6 liters via trach collar, continuous pulse oximetry. SaO2 96%. Call bell within reach. Reported off to primary nurse.

(This is just an example. Be sure any abbreviations you use are approved by the facility and your instructor! Otherwise, write out all abbreviations such as "pt" and "FSBS"! )

[Daytonite]

I just have to post this because it kind of relates to this thread. I was in the hospital for surgery this week and in between the pain and the grogginess, I had a good time schmoozing with the various RNs assigned to me. I want you all to know how important good documentation is. The hospital nurses worked 12-hour shifts 7a to 7p and 7p to 7a. Around 10am yesterday I walked out into the hallway and found my 7p to 7a RN sitting at an isolated desk toward the far end of the surgical unit--CHARTING! This was no new graduate as we had several conversations. She felt, as I did when I was actively working in the acute hospital, that it was more important to stay and finish charting and make it as thorough as possible.

Now, she may have a time management problem, but I cannot say. However, her purpose was certainly clear. She wanted the work she had done during her shift to be correctly and completely documented because you never know who is going to be looking at what you've written. I never apologized or complained about the times I stayed over to finish my charting. And, if my bosses gave me grief about it, I clocked out and finished my charting on my own time because I felt it was for my professional and personal benefit. There's no way I was ever going to have to be on a witness stand and be made to look like a boob by an attorney. If you've never seen it, watch the movie, The Verdict, and how the attorneys treat the doctors and the nurse who changes the outcome of the malpractice trial the story is about. While a lot of it is done for dramatic purposes, the real deal can be a lot harsher and colder. At one of the legal seminars I attended we were shown a 15-minute video of a nurse being questioned by an attorney. It was awful as the attorney pointed out all the things the nurse didn't do or chart what she had done. The lawyer made the nurse look incompetent. And all he did was act polite and ask nice questions that were designed to bring out the flaws in her documentation that he wanted the jury to hear. On top of that he had a huge blow up of her actual page of nurses notes for the jury to see. They were sloppy and there were several places where she had scratched out the information she had written (wrong way to correct a document).

[VickyRN]

Protecting Yourself from Malpractice Claims

Refer especially to page 40 in the article, Failure to Document.

[VickyRN]

Hand-off is the provision of verbal and/ or written
information from one primary health care provider to another so that pertinent care, treatment, or service needs as well as the patient’s current condition and
any recent or anticipated changes are accurately communicated.

SBAR is an acronym for situation, background, assessment, and recommendation.

Situation: Identify the patient and who is involved. Identify the problem/diagnosis, recent changes.

Background: Review of systems, pertinent medical history (allergies, code status, chronic diseases, and disability), safety/ cultural issues, precautions, labs, medications, mobility status, mental status, next of kin, equipment, tubes, drains, medications, IVs

Assessment: Plan of care, summary of current condition, catheters, drains, lines, tubes, treatments.

Recommendations: Pending tests, suggestions or requests, physicians’ orders, what is to happen, where, when, and how, to-do items, anticipated changes, and outstanding issues.

http://www.ihi.org/IHI/Topics/Patien...efingModel.htm

[Daytonite]

Recent threads that might be of interest to some:

• http://allnurses.com/forums/f8/how-make-soapie-note-253110.html - Help! - how to make a SOAPIE note
• http://allnurses.com/forums/f205/dar-note-help-252944.html - DAR Note Help
• http://allnurses.com/forums/f205/help-p-i-e-charting-cellulitis-303978.html - P.I.E. charting sample

Each include examples of these types of charting from my copy of Portable RN: The All-in-One Nursing Reference, third edition, published by Lippincott, Williams & Wilkins, 2007.

[VickyRN]

PowerPoint on Nursing Documentation from Delmarlearning.com:

http://www.delmarlearning.com/compan...apter%2010.ppt

[VickyRN]

EXCELLENT interactive exercises on charting/ documentation from freenursetutor.com :

http://www.freenursetutor.com/assess...harting/2.html

http://www.freenursetutor.com/assess...al-female.html

http://www.freenursetutor.com/assess...-basic--2.html

[VickyRN]

Notes on types of documentation:

http://faculty.mccfl.edu/martinh/Lev...umentation.htm

[kylani3]

thank you so much for posting this great website.

[SpookyCat]

Originally Posted by huladancer

Have you read Charting Made Incredibly Easy? I skimmed through it at the bookstore not too long ago and it seemed helpful. I suggest you go to your local bookstore and check it out. Here's a link for amazon.com that shows the cover of the book. Hope it helps.
http://www.amazon.com/gp/product/158...923363?ie=UTF8

I just bought this and it should arrive tomorrow. I hope I didn't waste the little cash I have as a student. However, I need all the help I can get when it comes to charting. Even though we do our clinical at a hospital which uses document by exception, our instructors make us do narrative. I hope this helps.