Documenting Tips?

[slauren]

Hi everyone,

Was wondering if any one has any tips for good documention or rule of "thumbs." I'm a new nurse and have been working for a few months. I notice all the other nurses have extremely generic/basic charting. I deal with a lot of psyche/confused residents and sometimes things will happen (behavior wise) and the nurses will constantly talk about it but they never document about it. I just remember in nursing school that I was told to be very meticulous with the charting but it is hard since no one else is. I was told today that I write a lot and that some of my writing might seem a little subjective and/or judgemental but I'm really stating what is going on. For example, resident who has to have every single PRN medication whenever they can have it then argues with the times even though you are just following orders of when it can be given.

I personally feel behavior documentation is important so that if something happens then the patient's character/behavior is documented and it might help whoever had that patient of when things happen or a lawsuit or something. But I'm the only one doing the behavior charting and now I'm wondering if it will bite me back in the future? I just don't want to set myself up for loosing a lawsuit if there ever is one or have people think I am judging my patients.

Any tips please???