Documentation Information Sites

  1. I am trying to find some good websites for me to use in reference to the do's and don'ts in documentation and charting. I need something that says everything on what I need to include in my nurse's notes, etc. Believe it or not NONE of my textbooks have ANYTHING about charting except who, what, where, how and why.

    Soemthing that gives examples (sample entries) on what to write would be good. Am planning on purchasing a book about this, but it is not possible right now since I will be paying a lot of car repairs plus my tuition and every dollar counts right now for the next 3 months.

    Thank You
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  2. 2 Comments

  3. by   rileygrl11
    When I was in nursing school we had a small book called a lab book xeroxed every quarter by the Nursing Department that contained awesome info we needed to know that put it all into one location for studying, etc. One thing it contained was the steps to changing a dressing, etc. and at the bottom it said "things to chart" and listed "size of wound, etc.". You may not have something like this but what I am getting at is that your instructors are there for you to pick their brains. Find an instructor you are comfortable with and ask for their input. I've been out for 1-1/2 years and I still wonder if I do it "correctly." The basics are the same but everyone has their own style and then there is policy you must abide by.

    Have you tried doing a search on google?

    Good luck!
  4. by   NRSKarenRN
    Here are some good articles:

    Charting by Exception:
    http://www.calnurse.org/cna/cal/junjul99/9cnjj99.html

    Can You Make Documentation Easier For Me?
    http://www.corexcel.com/html/documen...title.ceus.htm

    More sites w legal focus to keep you out of hot water:
    Charting Questions
    http://www.wwnurse.com/articles/lega...uestions.shtml

    How Poor Documentation Does Damage in the Courtroom
    by Sharon Schott, RN
    http://library.ahima.org/xpedio/grou...k1_018164.html

    Purposes Documentation Effective Documentation Ethical and Legal ...
    http://www.lmhealth.org/PR_Text/Heal...NAL%204.01.pdf

    LEGAL DOCUMENTATION STANDARDS
    http://www.ahima.org/infocenter/guidelines/ltcs/5.1.cfm
    Last edit by NRSKarenRN on Jul 26, '03

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