LEGAL NOTICE TO THE FOLLOWING ALLNURSES SUBSCRIBERS: Pixie.RN, JustBeachyNurse, monkeyhq, duskyjewel, and LadyFree28. An Order has been issued by the United States District Court for the District of Minnesota that affects you in the case EAST COAST TEST PREP LLC v. ALLNURSES.COM, INC. Click here for more information
Depends so much on the hospital... do they have computerized charting? I agree with essarge, you need to ask the hospital or your CI. The hospital I'm doing a rotation at right now gave us a list of what they considered within normal limits and anything else has to be charted (in a computerized system). Are you charting everything or just by exception? That makes a huge difference also....
Check with your instructors. At our school, we are all provided with copies of flow sheets and charting by exception sheets used by the hospitals we attend clinicals at. Also, I don't know if your school uses CAI's (computer assisted instruction), but we have a wonderful one that walks you through each kind of nurses' note and then lets you practice at the end.
All I did was highlight what you were looking for and got this site first. <embarrassed> Then I just narrowed the field to nursing careplans. You see the results. I'm glad it helped. Let me know if you need any more stuff from the net....I'll do my best to find the sites!