Paper Charting Help

mamamerlee, LPN · Mar 15, 2010

'Hand' charting is really no different from any other kind, except you actually have to use a pen, and be able to form coherent sentences with good spelling and reasonable grammar and punctuation.

Your orientation should include the expectations for charting at that facility, and any unit-specific issues. If you need guidance, there should be someone there to help you get started.

Best wishes!

Music in My Heart · Mar 15, 2010

- how would you chart your am assessment? we use flowsheets in addition to our narrative. i generally say something like, "pt. assessed - see flowsheet." to that i sometimes add some detail regarding lung sounds, loc, or circulation. i generally add a statement (presuming it's correct) like, "pt. denies pain, nausea, dizziness, and sob." i'll sometimes add a comment about the patient's pain -- some of my chronic pain folks are always in pain so i make sure to say something about their pain being "tolerable" or at "baseline"
-when do you chart? as soon as i'm able. i start with a note at the beginning of the shift that i received report and assumed care. i then do a quick hot-lap to make sure all my pt's are alive and apparently ok after which i add a quick note saying whether the patient is awake, asleep, alert, and - presuming it's the case - that there are "no signs or symptoms of acute distress."
-how often do you chart? by policy, q2 hrs.
-can you give examples of when you d/c an iv or start an iv? the proper documentation? "iv/sl d/c'd from (r fa, etc), catheter intact. dsg held in place 1 min then taped - no bleeding."
-how to chart pain? "pt denies pain above baseline" or "pt reports sharp pain (8/10) while coughing" or something like that. i also include a my interventions, patient coping strategies, and a follow-up about the effectiveness of the interventions.
-what do you chart if the patient hasnt changed from the am assessment and no needs or changes through out the day? "vital signs stable," "status unchanged," "pt. denies pain, nausea, sob..." and "no signs/symptoms of distress" are all things that i use as appropriate.
-any thing you feel is important to document or a good way to write something! be clear, factual, and succinct. chart any changes in vital function or indications thereof. imagine that your patient crumps or goes ama in the next 5 minutes, what would you want to be sure to remember if challenged at some point regarding your care? assume that you'll be on a witness stand being called to account for your horrible care and that you can't recall a darn thing -- what needs to be written down to prove that your care was actually to professional standards?
anything and every tip is appreciated! thanks

just my opinion

PAERRN20 · Mar 15, 2010

- How would you chart your AM assessment?

-When do you chart?

I chart anytime there is a change in patient condition, when a doctor visits the patient, when lab/PT/OT/ST is in the patients room, when the patient goes off the unit, etc.

-How often do you chart?

Q hour and prn

-Can you give examples of when you d/c an IV or start an IV? The proper documentation?

20 G aniocath IV started in left forearm with one attempt. Patient tolerated procedure well. Labs drawn from IV start and sent to lab. IV removed, site clear, catheter intact.

-How to chart pain?

Patient states pain 4/10 "it hurts in my back". Patient repositioned and given med per MAR.

-What do you chart if the patient hasnt changed from the AM assessment and no needs or changes through out the day?

Patient resting quietly. Able to voice needs- denies any needs at this time. Call bell within reach.

-Any thing you feel is IMPORTANT to document or a good way to write something!

kmgf316e · Mar 16, 2010

Thank you guys for the information! This really helped! I went to Books a Million last night and found a book "Charting made incredibly easy", I scanned through it and made notes and found it helpful! Just in case any one else was needing to look at something!