charting.... critique?

  1. OK, here I go... I'm putting this out here so y'all can tear me up. This is only my second attempt at documenting, and we don't use any charting books so I am really bad at how to phrase things. Anyone wanna critique me?? (PS - this isn't something we are graded on this quarter; we are doing it for practice) Thanks for any help!


    Charting for Friday, November 2
    11022007
    0705 Lying in bed, resting with eyes closed. Difficult to arouse. Apical P 70 & regular, R 24 rapid, shallow & irregular. Skin pink, cool, dry. Turgor good. Anterior lung sounds clear bilat. Ankles purple, dry, flaking, +4 pitting edema bilat. Feet and toes cool bilat. Tibial and pedal pulses not palpable bilat. Cap refill <3 bilat toes. Remains in bed with eyes closed. ---------------------------------S Smith SN

    0730 In bed, eyes closed, snoring. Difficult to awaken. A&O x2, disoriented to time. States wants to sleep longer. Remains in bed /c eyes closed.----------------------------------------------------S Sumith SN


    0815 In bed, eyes closed. Awakened /c difficulty. A&O x2, disoriented to time. Assist x2 to W/C. Assist x2 /c transfer to bathroom. Unable to void. Assist x1 to get dressed and return to W/C and transfer back to room. Resting quietly in W/C /c eyes closed, shallow resps.---------- S Smith SN

    0900 Sitting in W/C. A&O x3. Fistula L bicep warm, pulsating, dressing clean, dry and intact. Eating breakfast, denies further needs.-------------------------------------------------------------------S Smith SN


    0930 Sitting in W/C. Ate 50% of breakfast. Drank 100 mL tea, 100 mL milk. Denies needs at this time.---------------------------------------------------------------------------------------------------------S Smith SN


    0945 Sitting in W/C. Lung sounds clear posterior bilat. C/O pain in R knee, 2/10, refuses meds. Denies further needs.-------------------------------------------------------------------------------------S Smith SN


    1000 Sitting in W/C. Transfer to PT via W/C with assist x1.---------------------------------S SMith SN


    1115 Assist /c transfer to BR. Assist x2 onto toilet. Unable to void at present but states feeling of urgency. Assist x2 to W/C, back to room. Denies needs, remains in W/C.-----------------S Smith SN


    1140 Report given to LPN on duty.-----------------------------------------------------------------S Smith SN
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  2. 10 Comments

  3. by   Jolie
    It looks OK to me, but I'm a NICU nurse, so what do I know?

    My only suggestion would be to elaborate further on the knee pain. Is it new, or a chronic problem. Describe it more fully, (does it occur with motion, weight bearing, or all the time) and document the presence (or lack of) other s/s such as swelling, abrasion, or indication of injury. Offer non-pharmacological methods of pain relief such as warm pack, if appropriate.
  4. by   KEL2BanRN
    Quote from Jolie
    It looks OK to me, but I'm a NICU nurse, so what do I know?

    My only suggestion would be to elaborate further on the knee pain. Is it new, or a chronic problem. Describe it more fully, (does it occur with motion, weight bearing, or all the time) and document the presence (or lack of) other s/s such as swelling, abrasion, or indication of injury. Offer non-pharmacological methods of pain relief such as warm pack, if appropriate.
    Thanks I wondered what to do about the knee pain thing. Basically this is in a nursing home, and my resident mentioned that her arthritis was acting up in that knee. I wasn't sure how to do that...

    NICU huh? That's my goal someday in the future
  5. by   PsychNurseWannaBe
    I think it is good. Since he is difficult to arouse and alert and orientated x2... how about PERRLA and O2 sats. Also, if he is unable to void (1115), there should be an intervention. Did you just let him sit there in pain because he couldn't pee (probabaly not) or did you try something? Is this normal for him? Was there an order to straight cath? Did you inform the nurse? 1140 report to LPN does not count as informing... it's 35 minutes after the fact.

    But pretty nice
  6. by   KEL2BanRN
    Quote from PsychNurseWannaBe
    I think it is good. Since he is difficult to arouse and alert and orientated x2... how about PERRLA and O2 sats. Also, if he is unable to void (1115), there should be an intervention. Did you just let him sit there in pain because he couldn't pee (probabaly not) or did you try something? Is this normal for him? Was there an order to straight cath? Did you inform the nurse? 1140 report to LPN does not count as informing... it's 35 minutes after the fact.

    But pretty nice
    The reason there was no intervention is because my resident is on dialysis 3x week and she really never is able to "go" but once in a while she gets the urge so we help her onto the toilet. I figured I should doc that. She was not in pain, and yes this is normal for her. The 1140 report to LPN is just the end of my doc'ing for the day and my report off. They didn't need to be informed about the toileting. But thanks!
  7. by   Daytonite
    0705 lying in bed, resting with eyes closed. difficult to arouse. apical p 70 & regular, r 24 rapid, shallow & irregular. skin pink, cool, dry. turgor good. anterior lung sounds clear bilat. ankles purple, dry, flaking, +4 pitting edema bilat. feet and toes cool bilat. tibial and pedal pulses not palpable bilat. cap refill <3 bilat toes. remains in bed with eyes closed. ---------------------------------s smith sn
    0730 in bed, eyes closed, snoring. difficult to awaken. a&o x2, disoriented to time. states wants to sleep longer. remains in bed /c eyes closed.----------------------------------------------------s sumith sn
    lying in bed with eyes closed and snoring. oriented to person and place, but not to time. wants to sleep longer and remains in bed with eyes closed.
    0815 in bed, eyes closed. awakened /c difficulty. a&o x2, disoriented to time. assist x2 to w/c. assist x2 /c transfer to bathroom. unable to void. assist x1 to get dressed and return to w/c and transfer back to room. resting quietly in w/c /c eyes closed, shallow resps.---------- s smith sn
    remains in bed. oriented to person and place, but not time. required two assistants to assist to w/c to get to br, but unable to void. one assistant required to dress. transferred back to bed. respiration regular but shallow.
    0900 sitting in w/c. a&o x3. fistula l bicep warm, pulsating, dressing clean, dry and intact. eating breakfast, denies further needs.-------------------------------------------------------------------s smith sn
    sitting in w/c. a&o to person, place and time. dressing to left upper arm fistula clean, dry and intact. able to palpate thrill in fistula. eating breakfast.
    0930 sitting in w/c. ate 50% of breakfast. drank 100 ml tea, 100 ml milk. denies needs at this time.---------------------------------------------------------------------------------------------------------s smith sn
    remains up in w/c. ate 50% of breakfast. drank 100 ml of tea and 100ml of milk.
    0945 sitting in w/c. lung sounds clear posterior bilat. c/o pain in r knee, 2/10, refuses meds. denies further needs.-------------------------------------------------------------------------------------s smith sn
    continues to remain in w/c. posterior lung sound clear to auscultation. c/o pain in r knee 2/10 but refuses pain medication.
    1000 sitting in w/c. transfer to pt via w/c with assist x1.---------------------------------s smith sn
    to pt for therapy.
    1115 assist /c transfer to br. assist x2 onto toilet. unable to void at present but states feeling of urgency. assist x2 to w/c, back to room. denies needs, remains in w/c.-----------------s smith sn
    c/o of urgency to void. transfered to toilet with 2 assistants, but not able to void. transferred back to w/c and remains sitting up.
    1140 report given to lpn on duty.-----------------------------------------------------------------s smith sn
    question: did anyone address this lady's inability to pee?
  8. by   KEL2BanRN
    Daytonite, thank you! Yes, I explained it in a previous post. (about the inability to void)
  9. by   Imafloat
    I work in NICU too and we only chart in our narrative what isn't covered in our trifold so I am not sure how helpful my advice is. If there is something abnormal, I state what I am going to do about it, because "if it isn't charted it isn't done." I would say something along the lines of pt unable to void despite urgency, will continue to monitor.
  10. by   KEL2BanRN
    Quote from WeeBabyRN
    I work in NICU too and we only chart in our narrative what isn't covered in our trifold so I am not sure how helpful my advice is. If there is something abnormal, I state what I am going to do about it, because "if it isn't charted it isn't done." I would say something along the lines of pt unable to void despite urgency, will continue to monitor.
    Thank you, that is very helpful! I need examples, and no books I see really have very many.
  11. by   MrsHarrison0526
    the only thing that I noticed that hasn't been stressed which might just be a school thing... which you might want to consider since your IN school in all.. we have to chart every 2 hours and in the charting we have to note some kind of safety...like... bed in low locked position... call light within reach... room uncluttered... SR up X 2... adequate lighting... it's kinda CYA if u think about it... if that pt. falls.. you can ensure at this time when you went in and saw them you noted that the bed was locked and in low position they had none slip footwear and nothing was cluttered for them to trip over... so the chair that suddenly appeared that they fell over had to be moved there by someone...??? ya know?
  12. by   KEL2BanRN
    Quote from MrsHarrison0526
    the only thing that I noticed that hasn't been stressed which might just be a school thing... which you might want to consider since your IN school in all.. we have to chart every 2 hours and in the charting we have to note some kind of safety...like... bed in low locked position... call light within reach... room uncluttered... SR up X 2... adequate lighting... it's kinda CYA if u think about it... if that pt. falls.. you can ensure at this time when you went in and saw them you noted that the bed was locked and in low position they had none slip footwear and nothing was cluttered for them to trip over... so the chair that suddenly appeared that they fell over had to be moved there by someone...??? ya know?
    Yeah I realized just AFTER I posted that I forgot to put "call light in reach" with my entries!! DOH!! LOL

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