- 0Mar 26, '13 by truckinusaMy teacher wants me to be a pro at charting, but I've had very little experience and no teaching. Is there a book or some resource to I can read to get better at this?
- 0Mar 26, '13 by Floridatrail2006May 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.
- 1Mar 27, '13 by Esme12, BSN, RN Senior ModeratorThere 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.
From VickyRN asst admin.....