Charting format

  1. I'm working on my MSN and doing my admin clinical at a small (60 bed) rural hospital. They have an ancient charting form and want to update it to a flowsheet or charting by exception type of document. I am to help with this transition. I like the checklist types, but I am an occ health nurse and haven't practiced bedside nursing in a while.

    Input from anyone? Do you guys have a form you like? I am going to poll the nurses at the hospital but most of them are either brand new nurses or have only worked at this facility (forever and ever).

    Thanks for the assist!
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  2. 4 Comments

  3. by   deespoohbear
    Our facility is just getting ready to introduce new flow sheets too. We are a small facility about 80 beds total with 34 being med-surg/tele/peds. Our new flow sheets cover a 24 hour period and have everything on them except the graphics (which is a whole another thread). I will try to get a better look at them to see what is on there, but I know they have the little diagram people so you can chart wounds and such....We are trying to get the flow sheets to where we just have to do charting by exception....we still have the long hand written forms with just a basic flow sheet. Best wishes...
  4. by   dereklance
    same problem with me ,i am a member of the accreditation team ,surgical team and i dont even know where to start the amelioration.,i am in a dire need of help in these transitional involvement,the instituition im working with has been run by the ancient nursing professionals,,and documentation wise its really horrible,is anybody there want to help me...
  5. by   RNinSoCal
    Hello all,
    charting by exception forms worked really well at the last hospital I worked for when they transitioned from one charting system to another. There was a check box next to each system that said WNL and then clearly defined what that meant for each system. If there was something out of the WNL guidelines then the exception was charted on the blank lines to the right of the box. On the bottom of the form was space for IV site assessment and restraints assessment. On the back was a box for education and then a lot of blank lines for narrative. It was quick and easy. The hospital had been using Compubar charting (ancient bar code system) and was transitioning to Cerner, they used the paper forms until the new system was ready.
    I will look at home and see if I have one of the forms left over, it is just one 2 side page.
  6. by   Daytonite
    jackiemc08. . .i think that you will find many examples of check off assessments in the care plan books of carpenito. i've seen the critical pathways charting forms in carpenito's books as well as assessment forms that she has designed. while i have not seen carpenito's recent forms, i would venture to guess that they are designed to be merged with nursing diagnoses since carpenito has been an active member of nanda for many years. doenges has been very detailed in her care plan books in listing out assessment items that should be addressed for various types of patients. while they are not check off items, her's are simple short fill in answers. her adult medical/surgical assessment tool is organized by the diagnostic divisions that nanda has grouped the nursing diagnoses into, so it is also meant to be merged with nursing diagnoses. (nursing process is assess first and then choose nursing diagnoses from abnormal data obtained during data collection.) i have doenges' med/surg and maternity care plan books and she has assessment tools that are organized this way in both these books. the difference is that in the maternity care plan book, the assessment tools have items in them that are specifically tailored to the maternity patient. another place you might be able to get a look at some hospital forms that they let the public have free access to is on the hospital soup site. here's a link:

    http://www.4nursingmanagers.com/poli.../viewincat.htm - a list of some of the categories of forms that the site has available for free to the public. there are some nursing assessment forms available here that you can access.

    http://connection.lww.com/products/c...ondatabase.doc - an example of one of carpenito's admission assessment forms. i can't get access to the other sample forms that are online.

    i also have a number of links to assessment guidelines or forms from some of the various nursing schools around the country. these, however, were never designed to be hospital forms. they were developed by nursing instructors or nursing programs to assist students in learning how to complete a nursing assessment. i would be more than glad to go through my links and make a list of them for you if you want to see what is there.

    i have been studying health information management. i recall one of my instructors telling us that forms design is often something that is also managed or facilitated through the medical records, or health information management, department in order to assure continuity of all the forms being used in the patient chart. so, i would suggest that you ask if someone has given medical records, or health information management, a heads up that nursing is wanting a new form designed. the medical records, or health information management, staff might have access to samples of charting forms through their professional memberships in the american health information management association or other groups. i'm sad to say that i am also a member of ahima, but i'm not very proficient at navigating around their website although i will attempt to see if i can find any access to forms on there for you.

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