Need help with nurses notes

  1. can some one post a website address, that will explain how to write effective nurses notes? Every job that I have ever worked @ was charting by exxception. It is not like this @ my current place of employment.
    •  
  2. 8 Comments

  3. by   Dixiedi
    I have always charted gross observations followed by head to toe as my first assessment each shift.
    Then, for subsequesnt entries throughout the shift I stick to gross observation, followed by involved systems (head to toe order) followed by specifics of a tx or activity unless said specifics came into play with the systems entry.
    Pertinent equipment that doesn't fall into the entry elsewhere brings up the end.

    Just remember, always think 1)what is obvious when I walked in and 2) start at the top and work down. Doing this will help you always get everything in accurately.
  4. by   purplemania
    Also, contact your Education Dept. or Risk Management. They may have examples to share.
  5. by   webbiedebbie
    What type of charting does this hospital use?

    Where I work, we use PIE charting. It was hard to get used to at first, but now I find it a breeze to use.
  6. by   June55Baby
    Quote from webbiedebbie
    What type of charting does this hospital use?

    Where I work, we use PIE charting. It was hard to get used to at first, but now I find it a breeze to use.

    debbie,
    What is PIE Charting? I know about SOAP but never heard of PIE.
  7. by   Nurse Ratched
    PIE - guessing - problem, intervention, evaluation?

    We use SOAP also. Charting by exception at the hospital.
  8. by   Nurse Ratched
    http://www.corexcel.com/html/documen...title.ceus.htm

    Here's a good little course in the basics. No charge to take it - only if you wanted to get CEU's.
  9. by   SCRN1
    We chart on the computer where I work. Almost everything is listed. You simply add a check in the box beside what's going on in every system of that patient. Helps ya not to forget to chart something. If there's anything you'd like to add, there's a comment box to type that in. I love it!
  10. by   chris_at_lucas_RN
    We used "SOAPIE" notes.

    Subjective
    Objective
    Assessment
    Plan
    Intervention
    Evaluation

    Sometimes the best training I got on how to do something was watching someone who knew what they were doing, and doing what they did. Read the notes of nurses you respect... ask your new nurse manager for some help. I like the idea of the education and risk management department of the hospital as a resource too.

    And thanks for that URL. I'm always looking for ways to hone my skills.... It downloads using Acrobat Reader. I noticed a reference to the book Charting Made Incredibly Easy as well.
    Last edit by chris_at_lucas on Jun 23, '04

close