Lippincott publishes a book for nurses and students regarding correct charting methods. It is entitled Charting Made Incredibly Easy, and it can be found in any major bookstore in the medical/nursing section. I have a book called Surefire Documentation, which also has some good pointers on charting. The issue of charting is very important, because it can save you from being sued after bad patient outcome and will prove the care you provided.
Jun 28, '07
I have always charted what my head to toe assessment was, plus what they did, and any new orders, plus any other info that is pertinent to that patient. Something like.
PT alert and oriented x 3. 0 c/o pain or discomfort. skin w/d. LS clear. BS + x 4, abd soft and non-tender. +pp's. N.O. APAP 650mg po TID. PT inc of bladder x 3. 72h bowel/bladder screen started.