Can anyone help me find descriptive words for narrative charting? Yesterday I had to chart a wound that looked like it had been there for several days but had gone unnoticed. When I sat down to chart, I drew a blank. Couldn't put down on paper what it looked like.
Any advice? I saw a book called Chart Smart but I don't know if it is what I am looking for. I bought one of those pocket guides for wound care but it didn't help for charting.
I am an inactive nurse, however, I wanted to ask what is your line of report? You did report it to the preceptor. I would think that you would just chart what you observed and noted. Also, say that preceptor was notified. Always chart who you report to. As an LPN, I would chart that I reported to unit RN. Also, I would put them down on list for dr. consult for whatever reason. We learned in nursing school not to chart stages, however, in the facility that I worked at, we did stage them. However, I do agree that staging is quite subjective.
And, don't beat yourself up over this. We all learn through our mistakes, and we all make them. Especially being new, you will have a lot of learning. What we learn along the way makes us better nurses. And, someday you may be able to pass all of your knowledge on to a newbie.:wink2:
Just remember to CYA by documenting everything!
Last edit by iwanna on Aug 19, '08
: Reason: typo