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

  1. 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!
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  2. 13 Comments

  3. by   SouthernLPN2RN
    Quote from 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!
    First of all, you do have to do what the instructor wants, lol!! This is how I would chart the above
    0730-AM assessment complete. Pt A&O x3, VS:86/50-99.0-92-16. Resp equal, even and nonlabored, inspiratory wheezes noted RUL. All other lung fields clear. Abd flat, nontender, BS's + x4. Pt denies pain, sob; resting in bed with eyes open, semi-fowler's position. ....................................XXX
    I don't usually chart about bed rails and such does anyone else? Also, what's this pt's dx? Those vitals aren't so great.
  4. by   tvccrn
    Quote from southernlpn
    I don't usually chart about bed rails and such does anyone else?
    I would just to CYA. In this time of sue-happy people I think it makes sense to chart things such as this.
  5. by   crb613
    Quote from southernlpn
    First of all, you do have to do what the instructor wants, lol!! This is how I would chart the above
    0730-AM assessment complete. Pt A&O x3, VS:86/50-99.0-92-16. Resp equal, even and nonlabored, inspiratory wheezes noted RUL. All other lung fields clear. Abd flat, nontender, BS's + x4. Pt denies pain, sob; resting in bed with eyes open, semi-fowler's position. ....................................XXX
    I don't usually chart about bed rails and such does anyone else? Also, what's this pt's dx? Those vitals aren't so great.
    Thanks & the dx cancer.
    My CI says no to bedrails/call light also. No to vitals, BS's, Abd flat/non tender. Also don't say pt. its their chart......Instead The lung wheeze ok & denies pain,sob,any needs. Will monitor...................................xx
    I am just confused because I thought if you do not chart it you did not do it??? This is what I have been taught up to now. My CI says there is too much info & no one will read it cause they will not have time. So I said I would work on it & look at charting done by the nurse's at the clinical site to get a better handle on it. I was told no because they don't chart right either!:imbar
  6. by   crb613
    Quote from tvccrn
    I would just to CYA. In this time of sue-happy people I think it makes sense to chart things such as this.
    Thanks & this was the reasoning behind charting this. This is what I said to my CI.......did not really get an answer except, Well yes, but it does not need to charted????????????? Ok so if the client falls out of the bed......were the rails up or down & what position was the bed left in & did she have access to the call light so she would not try to get up on her own??? I am sooo confused.
  7. by   truern
    Get your CI to give you written examples of what she expects. That way you have the "proof" when she comes up with different expectations
  8. by   sabrn2006
    Does the facility have a flow sheet to document routine care like hygiene, lung sounds, bed rails, etc? If so, then putting it in the narrative would be double documenting. It does seem like this info should be available somewhere. I know that when writing notes at our hospital I would put something generic like "able to make needs known. will continue to monitor" along with the more specific info to that pt.

    Quote from crb613
    Thanks & this was the reasoning behind charting this. This is what I said to my CI.......did not really get an answer except, Well yes, but it does not need to charted????????????? Ok so if the client falls out of the bed......were the rails up or down & what position was the bed left in & did she have access to the call light so she would not try to get up on her own??? I am sooo confused.
  9. by   SouthernLPN2RN
    In real life, I always charted on a flowsheet. My actual note would look like this:
    0730-AM assessment complete, see flowsheet for details. Wheezes noted RUL, denies SOB, cont. to monitor. .............................................XXXX
    Or something to that effect, lol! I did put in there to "see flowsheet" just in case the papers ever got separated. That way the reader knew it had been documented elsewhere.
  10. by   crb613
    They do have a sheet hanging up that has Pt. care on it....baths, I&O's, ambulation ect the CNA's do this.They also do the vitals & have a sheet for them. Now I guess where I am confused is that what the CNA's do is documented but when the nurse is doing these things and the CNA's have already marked it on the sheet.......What do ya do? I just want it to be known that I am giving care, monitoring the pt & am leaving them in a safe enviro. doing my assessment & noting what is taking place. As a nursing student I of course do it all......& it would be documented as I am doing the CNA part as well. I hope I am making sense, just wondering if I am not documenting as a CNA but as a Nurse........How do I prove what went on. Did I mention I was confused?? Thanks to ya'll
  11. by   wengrn
    charting is an old issue in the college of nursing... when i was a student we used to follow the so-called SOAPIE (subjective, objective, assessment, planning, intervention, evaluation... duh!) in charting... as for me i don't need to chart something that is already existing in the assessment form, waste of time... with lots of paper works on the floor (especially when you have an admit), we tend to focus on the paperworks rather than the bedside care... something that was so frustrating for me when i was following up my students in the floor...

    just write what you see and do... assessment on lungs, abdomen, skin, etc - don't they appear in your assessment form? if there's any changes you see from the skin integrity on the previous day's assessment (e.g., it became worse), that's the only time you chart it... the VS? do we have to put it in the narrative report since it appears on the VS sheet already? if there's any issues about the vitals, write it... like, "BP suddenly dropped to 70/45, called the doctor, and made order..." make the narrative report (or charting) clear, concise, specific and short... that way, we have time to run when our dear patients call us and not making them wait because of the bloody paperworks kept piling up to our neck!
  12. by   bjm
    I would have charted something like this: Shift report received from J. Doe, RN. Pt received in semi fowlers position, a&o x 3, is able to voice needs ( or write needs, or shake head yes/no, etc), VS (fill in #'s), with resp even and nonlabored, denies SOB. S1, S2 auscultated, no murmurs noted, pulses x4 +2, cap refill <3 sec, wheezes noted to LUL, (no need to address other lung sounds since you have identified the abnormal) BSx4+, nontender, skin dry, intact, 0 edema. Will continue rounds q2 and prn, noting any changes. (Basically, I like to start at the head, address LOC, which includes ability and how communication is made. VS are always addressed at start of shift in critical care because there are "monitors", you may not always be able to address VS for all your floor pts at the start of shift. (remember on the floor you are making rounds, you are not monitoring- which implies tracking or recording) Then work your way down, address cardiac, respiratory, GI, and skin. What I feel is equally impt in that 1st note is to tell your reader (the lawyers) that you are going to be providing rounds on your pt and at what interval. I always went with q2 and prn because on the floor, I know that at minimum I will be in that room at least q2 but I will always be there prn, and that when I do, I will also be charting any changes.) I hope this helps.
  13. by   bjm
    Oh yea, I forgot to put in my previous note, when you start your note, Pt received semi fowlers, I forgot to also say, with rails x2 and bed in low position, pt able to voice needs........It is important to address those bed rails and position of bed. If pt falls, the first question that will arise is, was the bed in low position, what rails were in place, what fall percautions were in place. Sorry, see, we all forget an item or two when we are charting.
  14. by   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"
    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!

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