Charting/Nurses Notes

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    Charting/Nurses Notes

    Hello everyone, You all helped me so much with my Frequent Faller questions, So I have another question.

    I have to give an inservice on Charting. I work in a nurseing home and the charting can, at times, be very minimal and often confusing. Does any one have some hints for the inservice? Or does anyone know where I might find information on the internet?? I'd like to teach my co-workers to chart more detailed information, knowing that this may save lots of problems in the future...thanks in advance...

    StormyCD
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  3. 22 Comments so far...

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    Have you seen the new Springhouse book called, I think, Smart Charting, or something like that? It has some good basic examples.
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    At my facility I have a program in place called aler charting --I have found that no matter how much inservicing I do on charting accurately and thouroughly it doesn't happen. I know that it doesn't happen because of time!! let's face it, charting is the last thing everybody wants to do!!! So I put out the alert charting list and it includes all the every shift documentation and the med A documentation. I write down exaclty what needs to be assessed--for example: Jane- URI- Document lung sounds, temp, respiratory rate/quality, o2 sats and orientation. I keep this on until the URI is resolved. It improves the follow through. If you would like the form you can e mail me and give me a fax number. I also have a few other documentation inservices that I have presented that I could fax you.
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    zuchRN

    this is in case the email doesn't go through.....My fax number at work is 915-263-1489. Just be sure and put Attention Treasa Wells R.N....I'd like all the information you can spare....and thanks again for all your help

    StormyCD
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    Quote from zuchRN
    At my facility I have a program in place called aler charting --I have found that no matter how much inservicing I do on charting accurately and thouroughly it doesn't happen. I know that it doesn't happen because of time!! let's face it, charting is the last thing everybody wants to do!!! So I put out the alert charting list and it includes all the every shift documentation and the med A documentation. I write down exaclty what needs to be assessed--for example: Jane- URI- Document lung sounds, temp, respiratory rate/quality, o2 sats and orientation. I keep this on until the URI is resolved. It improves the follow through. If you would like the form you can e mail me and give me a fax number. I also have a few other documentation inservices that I have presented that I could fax you.
    HI IWOULD LIKE YOU TO FAX ME THE INFO ON CHARTING TO IF YOU WOULD PLEASE AND THANK YOU SO MUCH MY FAX NUMBER AT WORK IS 317-894-1073
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    Quote from zuchRN
    At my facility I have a program in place called aler charting --I have found that no matter how much inservicing I do on charting accurately and thouroughly it doesn't happen. I know that it doesn't happen because of time!! let's face it, charting is the last thing everybody wants to do!!! So I put out the alert charting list and it includes all the every shift documentation and the med A documentation. I write down exaclty what needs to be assessed--for example: Jane- URI- Document lung sounds, temp, respiratory rate/quality, o2 sats and orientation. I keep this on until the URI is resolved. It improves the follow through. If you would like the form you can e mail me and give me a fax number. I also have a few other documentation inservices that I have presented that I could fax you.
    Can you please fax me too any thing you can about documentation. I need help. I e-mailed you but if it doesnt work my no. is 940-686-2323 Attenion Jenny
    Thanks a bunch
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    Quote from Jdon
    Can you please fax me too any thing you can about documentation. I need help. I e-mailed you but if it doesnt work my no. is 940-686-2323 Attenion Jenny
    Thanks a bunch
    this is brown eyes my fax number is 3178941073 and i will do the same thank you very much
  10. 0
    hi

    have you tried potter and perry's fundamental nursing textbook? it gives a basic information about charting, including what to include, how to correct mistakes, etc... also my textbook from my last nursing class has alot of good information. i alway keep in mind when i'm charting that my charting is going to back me up when there is going to be a lawsuit, and it has saved me quite a few times to protect my license, example when doctors dont return calls...
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    Hi , I was wondering about charting also. But my question is ... How many LTC facilities are using computers for charting ? In fact do hospitals use computers for charting ? I was told by my DON that it is coming soon to our facility . I think this would be better. There is always someone that wants the chart at the same that that I need it to do my charting . What does everyone think about this ?
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    Quote from dotty865
    Hi , I was wondering about charting also. But my question is ... How many LTC facilities are using computers for charting ? In fact do hospitals use computers for charting ? I was told by my DON that it is coming soon to our facility . I think this would be better. There is always someone that wants the chart at the same that that I need it to do my charting . What does everyone think about this ?
    We chart on the computer. It is much easier. The charts are neater and lets face it some of us have awful handwriting.


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