Charting do's and don'ts

vivibonita · Apr 11, 2008

I feel bad for waking up this thread.. but i have a question. I just started working at an LTC, I'm a brand new nurse and finally got a job. I like all your guys' responses on how and what to chart... but would you chart that on all of your pts??? I was taught to chart: "Pt. alert and oriented (or confused), able tomake needs known. No c/o pain or discomfort. No signs of distress noted. Respirations even and unlabored. All needs met and attended by staff. All meds given as ordered. Call light within reach. Will continue to monitor."

and then you can add...

"Cont. on Antibiotic therapy, with no adverse side effects..."

"Pt. c/o pain 6/10, gave so and so med as ordered..."

I don't know if this is right, i'm really nervous that some day some lawyer pulls my charts and finds out that most of them sound the same. I try to vary every now and then but i feel like i'm missing something, like something is wrong. It is pretty scary. After you give pain med... do you chart if it was effective or not? what other things would you chart on. I'm only passing meds, so my contact with the pt is usually minimal.

Please help!!! :sstrs: