I need help w/charting please........

[crb613]

I am a student & not sure how to chart. It seems if I include something my instructor says I should not have & if I didn't......then of course I should have!

This is an ex. of what I charted & it was wrong any advice appreciated.

0730-Assumed care. Assessment complete. Resting in bed, semi-fowlers position w/eyes open. A&Ox3, b/p 86/50, p 92, t99.0, r16 even nonlabored. No jvd. Wheeze to url on inspiration, Lungs clear LL bilaterally.Chest equal. Abdomen flat, non tender. Bowel sounds ax4q. Denies dyspnea,sob, pain, or needs at this time.Bed low position, rails up x2, call light in reach.............CB

Thank you!

[achot chavi]

Wow! What an interesting situation. When I was a student I learned that with 4 different instructors you will get 5 different opinions about charting. In truth as a student you have to do as the teacher instructs and try to learn from them. There is a reason that they are the teacher and even if you disagree, they have to pass you....not the other way around:roll

Having made that clear, it is also true that "Those who can't do, teach":specs:

You will be learning your whole life and certainly you will be growing and learning and evolving as a nurse your entire career. So don't take this whole thing so personally.

Your teacher is trying to bring home the point that in nurses notes

brevity is valued as people don't have the time to read everything if they are to provide care and then do their own charting. If you already charted V/S on a flowsheet I wouldnt repeat them unless they are out of the ordinary for that patient or if you actually did something about them (like inform the doctor or give a medication SOS) likewise with other details.

OTOH you do have to practice CYA charting or you might find yourself out of a license!! Heres my story

I sent a 101 Y.O. female with severe COPD, SOB, and other problems from our SNF to an ER and in the transfer note I wrote a boiler plate "skin turgor good". Turns out the ER ignored her and she sat for 16 HOURS in some corner till someone noticed that she had no vitals. It was determined that she died of dehydration (not having eaten or drunken that whole time). They hospital sued us for sending her in a state of dehydration and the lawyer defended us based on my inclusion of good skin turgor. Boy did I get a pat on my back!!

Anyway school is always rough, stick it our and LOL!

[crb613, BSN, RN]

Thanks to you all...its starting to come together. I appreciate your help & taking time to "splain things" to me. I think I will also ask (as was suggested) for my CI to chart on my client.....then I can see what she wants. She is from the north, I am from the south & things get lost in the wording! :chuckle Thanks again!