How do you document what you have done?

  1. I'm curious as to how you document what you have done like giving injection or taking vitals? Does any one have any examples? Thanks
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  2. 6 Comments

  3. by   S.T.A.C.E.Y
    Injection goes on the MAR....we just sign in the little box to say it was done & went well

    Vitals just get written on the Vitals record sheet. Numbers, no description. Unless theres something to note, then it goes into the Nursing notes with ur assessment findings.
  4. by   loriangel14
    I just did my first acute care placement and we had to do computer charting.Vitals had places for info like what kind of thermometer,what position were they in, which arm etc.For bp it asked what kind of cuff and again what position they were in.For respirations it asks if resps were labored or non-labored. I know for paper charting you just record the numbers.
  5. by   guy_nurse
    Quote from jlhalloween
    I'm curious as to how you document what you have done like giving injection or taking vitals? Does any one have any examples? Thanks
    Are you refering to the Nurses notes? If so here is what we are being taught.

    1800 B/P 136/84 P 78 T 99.3 R 15 o2 96% reports resting comfortably
    then we just sign it J.Doe SN/SU---------------------------
    I "believe" that the MAR is the only documentation of record for administering meds.

    Does this help?
  6. by   jlhalloween
    Yes, it does help. Thank you so much!
  7. by   Chaya
    We were taught to document any PRN meds given in the progress notes as well as response to the med.
  8. by   guy_nurse
    Quote from Chaya
    We were taught to document any PRN meds given in the progress notes as well as response to the med.
    You are correct, we are being taught to document PRN meds as well, because they are not "regularly scheduled" meds.

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