Med Surg Charting HELP!

[jmlxy]

I am a nursing student and on med surg floor this term. I use a narrative charting template provided by our school which was used when I was on my medicine floor. My instructor will check our draft before we can transcribe to the progress notes.

For charting by exceptions, she always said that I missed important data and was not happy on my charting AT ALL. She said I should chart by actual or potential problems and recommended to use DAR format when charting. I tried my best to do so but still having problems! She said my charting did not reflect my critical thinking of nursing process.

In our program, we will do thorough patient researches and medications before clinical, so we would anticipate patient's problems. I did thorough assessments every time but identifying a problem/problems is not easy, especially when the problem I do not anticipate (example: I have a post op day 1 patient who shows s/s of sepsis). I do not know what I could do to help my nursing process and better charting. I am confused. Please help!!!!

[Rose_Queen, BSN, MSN, RN]

Have you requested to meet with your instructor to clarify the expectations? Since she is the one grading you, it would be best to go to her directly.

[jmlxy]

Have you requested to meet with your instructor to clarify the expectations? Since she is the one grading you, it would be best to go to her directly.

I discussed it with her around midterm. She said that I should have charted RELEVANT findings for a problem, though I still need to chart all assessments done for any involved systems.

After that, I tried so hard to chart the data based on what she explained but the outcome was same. I really want to master charting cause I spent too much time on it during the shift just because I had to "guess" what my instructor wanted. It sounds horrible and I am so stressed by her now.

How can I tackle this? Is there examples, resources that can better explain this type of charting?

[vintagemother, BSN, CNA, LVN, RN]

Have you requested to meet with your instructor to clarify the expectations? Since she is the one grading you, it would be best to go to her directly.

Hi RoseQueen! I understand it might sound glib when I echo the sentiment that you should meet with your professor to learn get expectations. However, as an RN student, I highly recommend that you schedule an office hours meeting with her soon! Take notes on what she says so that you can learn to write the way she wants. Please believe me, I was in your shoes last semester!

Another thing I learned to do is to ask the floor nurses to look at my charting before I saved it and asked them to help me with the instructors expectations. While this wasn't always feasible due to time restraints, I felt I did learn more from the actual working nurses about charting than I did learn from my instructor.

However, I needed, and you need, to earn a good grade and that requires meeting your instructors expectations.

[UCFAshley]

I'm not a nursing student (yet), so I may be not help. Can you get with another student and see how he or she is approaching the assignment?

[jmlxy]

Hi RoseQueen! I understand it might sound glib when I echo the sentiment that you should meet with your professor to learn get expectations. However, as an RN student, I highly recommend that you schedule an office hours meeting with her soon! Take notes on what she says so that you can learn to write the way she wants. Please believe me, I was in your shoes last semester!

Another thing I learned to do is to ask the floor nurses to look at my charting before I saved it and asked them to help me with the instructors expectations. While this wasn't always feasible due to time restraints, I felt I did learn more from the actual working nurses about charting than I did learn from my instructor.

However, I needed, and you need, to earn a good grade and that requires meeting your instructors expectations.

Thank you vintagemother! I definitely will. I also need to seek out other help myself too. As you mentioned, I might try asking help from RNs or peers if they are available. I know if I completely understand how to chart properly for this format and have some feedback from others, I will do it much better.

[pastory mange]

Hi Am a BSN 3 student and am in clinical practice in surgical ward my instructor told me to prepare the nursing care plan for the head injury client, I tried it ,but I experience difficult on what priority of care, and possible nursing diagnosis should i consider?

[jmlxy]

Hi Am a BSN 3 student and am in clinical practice in surgical ward my instructor told me to prepare the nursing care plan for the head injury client, I tried it ,but I experience difficult on what priority of care, and possible nursing diagnosis should i consider?

Can you tell me what you have in mind? So far I didn't encounter any head injury patients (yet). I would say neuro function and care would be your priority. So make sure to do thorough neuro foci assessments. here is a link I found might be helpful Nursing Care Plan For Acute Head Injury ~ NURSING DIAGNOSES

[vintagemother, BSN, CNA, LVN, RN]

Hi Am a BSN 3 student and am in clinical practice in surgical ward my instructor told me to prepare the nursing care plan for the head injury client, I tried it ,but I experience difficult on what priority of care, and possible nursing diagnosis should i consider?

ABCs, pain, then safety seen to pretty much work for be as far as prioritizing nursing priorities.

If there's no ABCs relevant, go to Maslows hierarchy.

But I would think, in neuro, ABCs would be relevant.