handwritten charting

guest042302019, BSN, RN · Mar 27, 2013

May I say that you will probably not be a pro at much of anything while in school except reading pathophysiology, looking up medications, and creating care plans.

With that being said, this is an answer for google. I typed in, "nursing documentation resources" or, "nursing documentation examples" and came up with some decent examples.

Charting, by hand or manually, is likely a skill mainly developed out of school. Your fundamentals book or other nursing books will have charting advice/tips. Check out the index. Furthermore, I would venture to say that charting by hand is a dying art because of the computer programs out there.

Continue searching on google. Save your money. Google is free, practically infinite resource.

Good Luck.

-Andrew

Esme12, ASN, BSN, RN · Mar 27, 2013

There are different "formulas" to follow for narrative charting. These will vary facility to facility. A common mnemonic......SBAR.

SBAR is an acronym for situation, background, assessment, and recommendation.

Situation: Identify the patient and who is involved. Identify the problem/diagnosis, recent changes.

Background: Review of systems, pertinent medical history (allergies, code status, chronic diseases, and disability), safety/ cultural issues, precautions, labs, medications, mobility status, mental status, next of kin, equipment, tubes, drains, medications, IVs

Assessment: Plan of care, summary of current condition, catheters, drains, lines, tubes, treatments.

Recommendations: Pending tests, suggestions or requests, physicians’ orders, what is to happen, where, when, and how, to-do items, anticipated changes, and outstanding issues

This thread is old and some of the links might not be active but it is a great thread on documentation.

https://allnurses.com/nursing-student-assistance/nursing-documentation-168921-page3.html

From VickyRN asst admin.....

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