what is the difference between nursing notes and charting

[bernikitty]

i'm a third semester nursing student and about to begin this semesters clinicals. when going over the paperwork, my instructor said at the end of the clinical day we have to turn in a physical assessment, charting and nursing notes.

can someone distinguish the difference between nursing notes and charting?

thanks

stacey

[NeoPediRN]

Charting is anything you put in the computer. Hospitals have electronic documentation, so your I&O, assessments, IV site documentation, safety (siderails, bed alarms, etc) all gets checked off in boxes usually. Nurses notes are considered charting, but most places now chart by exception - meaning you don't have to write a full note on your patient every shift, only when something nonroutine occurs, such as IV site infiltration, abnormal vital signs and your response to them, any testing the patient goes for, etc....hope that helps.

[classicdame, MSN, EdD]

nursing notes are considered to be the notes (perhaps in narrative form) that indicates times when things were said or done. Charting could include all in the above post plus graphs. Notes are more your interpretation. Charting is purely objective.

[xtxrn, ASN, RN]

I think it depends on the facility. I've heard charting used as a catch all for any documentation; nurses notes for only narrative notes, and anything in between w/checklists, graphs, etc.

[APRN., DNP, RN, APRN, NP]

After over 20 years in nursing, my somewhat jaded response is: Nurses notes are what no one (especially the docs) ever looks at, and charting is the documentation of the tangible evidence of patient status i.e. v/s, skin color, etc. (LOL)

[loriangel14, RN]

Where I work we do computer charting by exception. We write a "Focus Note" if something out of the usual or something to be noted happens such as a fall, a new symptom,behaviour issues.We also refer to these as nursing notes.

[nurseprnRN, BSN, RN]

for my money, nurse's notes are the narrative words that only nurses (by virtue of their experience, skills, and licensure) can write. this is in contrast to other documentary but nondescriptive pieces.

[tyvin, BSN, RN]

And then there are the progress notes (lol). The point I make is that they are different in everyones place of practice. If I were you I would ask the teacher. After all you are a student. Don't let the little stuff frustrate you. There are no stupid questions.

[Jenni811, RN]

Nursing notes to us is a little blurb of the patient in a summary. When you go into a patients room there is certain information that is nice to know. It's not usually part of the patients documentation, but communication between nurses. for example

"Patient admitted with CP on 9/2. Cath to R groin. No bleeding/hematoma. Up with SBA. General Diet. A&O"

and so on. usually a little longer, but you get the jist.

Documentation is apart of the patients chart. So documentation is assessments, IV fluids, medications etc.

[eagle78]

After over 20 years in nursing, my somewhat jaded response is: Nurses notes are what no one (especially the docs) ever looks at, and charting is the documentation of the tangible evidence of patient status i.e. v/s, skin color, etc. (LOL)

You mean the stuff that is admissible in court???

[lrobinson5]

All the responses have it correct. Charting is on a flow sheet, computer etc. The nurses notes are usually what you fill out if you either a.) don't have a box to check, or b.) something is abnormal and you need to write down what you are going to do about it. You HAVE to document what you do or else it never happened. This is the only defense you will have in court.