I am a new grad in my first weeks of orientation. I work in a facility that uses computer charting with flowsheets for everything (!) and charting by exception. My preceptor wants me to paint a picture with my opening note of how I have received the patient. I want to be able to include pertinent data, without getting wordy and charting what will be on the assessment flowsheet. Can anyone give me some ideas of what you would include?
Thanks! I want to work smarter, not harder, and have more time to be with my patients!
Nov 2, '11
We don't do "opening notes" and I have never heard of them. We have a 100% EMR and we have a section to chart by exception, too. There I always put the name of the RN who gave me report and make a little note, "bedside report given" or "bedside report received" or something like that.
Nov 3, '11
My "opening note" only consists of "Received report from ______, RN." But if your preceptor wants you to paint a brief picture of the patient, I'd stick with objective things. "Patient awake, alert, resting supine watching TV. No S/S of distress, denies pain or needs. Will monitor." That's usually what I chart when I'm doing hourly rounding. Their position (supine in bed), what the patient is doing (watching TV), how they look (no distress), and if they voiced any complaints or issues.
Nov 3, '11
Thanks, JustEnuff...that's pretty much what I was doing. I will expand a bit to satisfy my preceptor during my orientation, but go with your idea once I am on my own. I want to be able to do and chart my assessments early in my shift and then do patient care notes when there is a change of condition or a doctor comes, family concerns, etc.
Nov 4, '11
You should probably do what your preceptor recommends; each facility has different expectations. In my facility, the opening note is when the pt arrives on the unit. The expectation is that you note the pt's arrival, how they were able to move from the cart to the bed, any outside medical items (walker, foley, wound vac, etc), and orientation.
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