charting

  1. As a new nurse working in a hospital I am having a hard time writing progress notes, assessment notes, and transfer notes. What do I say? How do I go about it so that it makes sense? What kinds of GUIDELINES have you used to write your nurse notes? How do you know what to write about, and when to write something? All help will be greatly appreciated. thanks
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  2. 4 Comments

  3. by   NCNocRN
    Last edit by NCNocRN on May 15, '04
  4. by   Hearts
    Thank you for your reply. The patients on my unit are on TELE, and they are adults. We do use flow sheets with check offs. THe unit is super busy with many transfers in and out from cardiac cath. Sadly, they are too busy and short of staff to orient new grads properly.
  5. by   cargal
    Hi maybe this will help:
    Look at the patient and his main complaint.
    what presents? Is there chest pain or any other kind of pain?, cardiac status, lower leg edema etc, and the treatment that he/she is recieving. Is it helpful? Resolved? Look at your intervention ex nitro X 3. Has the problem subsided? Has the MD been notified? Any new orders? Also LOC, color , vitals q4-8, voiding? Other major medical complaints.Takes po meds s dif. Swal probs?
    IV intact and side effects? Give a picture to the nurse coming in on the next shift or a MD looking to see whats going on. Amb c dif c wheeled walker 10ft. SOB? Gait slow and steady? etc
    Hope this helps.. Also I usually chart "pleasant" if so, this tells alot
    The above can be with held if on flow chart, but written if need something to write, or just practice. Let me know how it goes. The skilled unit usually has charting tips , you can ask someone in that dept.
  6. by   pickledpepperRN
    Agree with advice given so far. I would include on tele lung sounds, pedal pulses, site checks where cath was performed, teaching of patient, rhythm, murmur if present,color,ask about nausea and pain, as well as anything else the patient says about physical or pshchological feelings. A lot but it can be done quickly. If you don't get the training you need PLEASE let management know in writing that you need more help in order to give safe care. How dare they do this to nurses and patients?
    Let them know and I pray you are pleasantly surprised by having a resource nurse assigned to advise you. This nurse should have a lighter assignment. If it does not happen keep a copy of your letter.

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