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!