[irmaRN]

hi... can anyone give me some tips on how to better document on my patients as an er nurse? i thought i was doing "ok" but according to my boss i am not.

[Altra]

Hello IrmaRN ... what kind of charting system do you use? Paper or computer-based? What comments have you received from your manager?

Hope we can help.


To the Moderators ... move to Emergency Nursing Forum?

[irmaRN]

hi.. we use paper charting in the er where i work.. we are all supposed to document every 2 hours on our patients and for the most part i do... maybe i am writing down the wrong things?

[silentfades]

Great question -- but my question is why would your NM/Boss tell you your not doing adequete work but not help you to reach the standards he/she would like too see ?

The basis I have used for initial assessment is the following questions/NOTES.

START WITH NAME DATE AND TIME SEEN ON ALL PAGES

NOTE IS THE PATIENT STABLE ENOUGH TO OBT HISTORY IE ACUTE MILD MODERATE OR NO DISTRESS

I note age sex race / is the patient a good historian ? is family answering questions ? Do they have a primary health care provider when was the last time seen and does he /she know about this problem -NOTE THE HEALTH CARE PROVIDES NAME PHONE NUMBER IF THE PT CAN PROVIDE IT/


THESE ARE EXCELLANT BASE QUESTIONS TO OBT AN IDEA OF WHAT IS REALLY GOING ON ....
CC: what is the patient saying that is wrong that they seek the ER
ONSET:When did the problem as they see it begin?
TIMING Are the symptoms continuous or do they come and go?
DURATION:How long do the symptoms last?
INTENSITY:and COURSE Are the symptoms mild, moderate or severe and are they getting better getting woorse staying the same
ARRAVATORS /RELIEVERS what trigger OR make the symptoms better
PAST TREATMENTS:What measures have you undertaken to relieve the sx?
HISTORY Have you had similar symptoms in the past, and how were they treated?

mild, moderate or severe distress today what would on 1/10 grade the symptoms ?

Then present med . Allergies .
past surgeries / significant pmhx they have seen a health provider for

basic review of sx -- ie PERTINENT TO PRESENTING PROBLEM
General: Denies fever, chills, anorexia, weight loss, weight gain, fatigue.
Eyes: Denies blurring/ diplopia/ vision loss.Ears: Denies pain, discharge, tinnitus.
Nose:Denies obstruction, discharge, sinus tenderness, epistaxis.
Mouth: Denies dyphagia, sore throat, stomatitis, .
Cardio:Denies chest pain, palpitation, peripheral edema.
Resp:Denies cough, SOB, dyspnea, /GI: Denies N/V/D/C. No change in stool. No abdominal pain/GU:Denies dysuria, discharge,genital sores.
MSK:Denies joint pain, swelling, muscle cramp, weakness.
Skin:Denies lesions, sores, rash, bruising./Neuro:Denies alteration in balance, head injury, /Psych: Denies hallucination, suicidal or homicidal intentions, anxiety,
Endo: Denies heat/cold intolerance, poly dipsia, pagia, or uria.

THEN OBTAIN VITALS --
DO AN ASSESSMENT AND PLAN
NOTE ANY SERIOUS COMPLICATIONS TO WATCH FOR OR IMMEDIATE INTERVENTION THAT NEED TO BE DONE AND WHAT WAS DONE AT WHAT TIME


YOU MAY WANT TO
1) READ ER NURSING JOURNALS AND
2) PURCHASE A GUIDE TO NURSING ASSESSMENT
3)NOTE SOME OF THE IMPORTANT FACTS ON A INDEX CARD AND CARRY IT TO WORK TILL YOU KNOW IT BY HEART --
4) READ THE ER POLICY AND PROCEDURE MANUAL
5) IF YOUR ER HAS ONE -- ASK THE PRECEPTOR TO LOOK OVER YOUR NOTES SO THAT YOU CAN IMPROVE YOUR SKILLS TO SEE WHAT IS LACKING OR ASK THE "BOSS" TO HELP YOU BY REVIEWING WITH YOU AND GIVING YOU WHAT IS MISSING-- TELL HER/ HIM YOU WANT TO IMPROVE.


TRUST YOURSELF IT WILL COME IN TIME


I HOPE THIS HELPED AND I JUST REALIZED I DID THIS IN ALL CAPS
SORRY

MARC

[TazziRN]

Do you do your own charges on each of your pts? That's how my charting improved, and I'm also in charge of teaching our staff the new charge system. Most of the staff have really improved their charting this way, although there are a couple of stubborn hold-outs.

If you charge on your own pts, get to know what's on it very well, then document to support your charges.