We have paper flowsheets that are 8 pages long, then another sheet for our plan of care, another sheet for skin assessment, another sheet for restraints, another sheet for heparin gtt titration, another sheet for insulin gtt titration, a sheet for patient education. I'm probably leaving something out, but that's what I can think of off the top of my head. So, a lot of stuff that I do throughout the shift is captured in one way or another on these documentation sheets. I have read/heard that it is not good to "double chart" i.e. write something on the flowsheet, then re-write it in your note. This is because any discrepancy could be used against you in court, i.e. on the MAR, you indicate you gave a med at 2015, and in your note, you write 2010.
At any rate, I am probably an "over-charter". I write a fairly lengthy note at the beginning of shift. It usually write "Received report from XXXXX RN, assumed care" then describe the patient's LOC i.e. "A/Ox3, with periods of confusion" or "Responds to vigorous verbal stimuli, follows commands, unable to assess orientation d/t intubation but responds appropriately to Y/N questions." I make sure to always address respiratory status i.e. "Lungs clear but dim in bases, resps even and unlabored, O2 per 2LNC" or "Vented per ETT at 40% FiO2, IMV 8/500/+5 PEEP." Then I describe any "abnormal" findings on assessment especially if they are related to admitting diagnosis i.e., "+3 edema to RUE, pedal pulses non-palpable, confirmed by doppler, ecchymosis to L orbit, decreased bowel sounds". I make sure to document any lines/tubes/drains i.e., "NGT to LIS with thin green drainage, or Gtube with Pulmocare at 40 mL/hr, or Foley draining cloudy amber urine with sediment, JP drain to midline incision with bright red thin drainage, AVF to RUE with +bruit/+thrill". I describe any gtts or IVF and where they are infusing i.e. "NS @ 150 mL/hr to RUA PICC dated 4/15/10, or Propofol at 40 mcg/kg/min to LIJ TLC dated 4/15/10." I also make sure to describe any wounds/incisions i.e., "midline abdominal incision, OTA, approximated with staples, edges dry and pink, no erythema or exudate observed" or "multiple area of skin sloughing to RLE, cold to touch, toes black, pedal pulse absent on doppler". Then I document any safety measures i.e, "SCDs to BLE, or soft wrist restraints to BUE, see restraint flowsheet, or bed alarm on, or Prevalon boot to LLE". I also document any education or instructions given to the patient i.e. "Reminded patient of NPO status after MN for stress test in AM, verbalized understanding" or "Instructed pt to call for assistance and rise slowly from bed, verbalized understanding, call bell in reach".
Then, I chart anything significant (not routine turning, mouth care, or bath) I do during the shift such as:
*Calling critical labs or changes in condition to the MD, what time I paged them, when they returned my call, if new orders are given, etc.
*Changing dressings to wounds, central lines.
*When I give PRN meds and why
*When I initiate or titrate gtts and why
*Any procedures, such as placing an NGT, foley, or INT
*Changing O2 modes and why
Then I write a brief note at end of shift i.e., "Pt asleep in bed, resps even and unlabored, cont on vent on same settings, pt remains NPO, VSS, NAD."
Sorry for the long post. Hope it helps answer your question.