Nursing Progress notes
- 0Feb 8, '09 by algrewetHi..I was wondering if anyone might be able to offer some tips as to writing nursing progress notes. I started a Nurse Tech role and will be writing progress notes on my patients but it seems I am not sure what to write..I was told everything you learn in school will not be used in the hospital scene. We would be charting by exception. Any tips? Or a template I might be able to follow?
- 0Feb 9, '09 by Daytonitehave you started your job yet? did you attend an orientation?
with charting by exception the form they use will have assessment items on it that you will check off so you won't have to do any writing. if the form doesn't have something about the patient that you found abnormal then you will have to write it out in long hand. the idea behind charting by exception is to save the nurses time. you'll see once you get a look at the forms they use.
- 0Actually the orientation I had in my job didn't tell us anything about progress notes. I just assumed I would be doing what I learned in nursing school. The nurse who worked with me yesterday said "didn't they tell you we don't chart like we were told in nursing school?" I ran into a writers block and didn't know what to do.
- 0Feb 9, '09 by DaytoniteOK, you need to talk to your supervisor or manager about this. It is inappropriate to be asking for assistance about how to do something on your job here on a public forum. Your manager is responsible for explaining this to you or they need to assign someone to explain it to you. Saying "we don't chart like we were told in nursing school" isn't explicit enough.
- 0Feb 9, '09 by pandora72I was told the same thing when I started my first job. In my situation, it meant all the detail I had grown accustomed to in school wasn't necessary. My first few months on the job, I'd write a half page note addressing everything I had observed head to toe because in school instructors assumed if you didn't write something it meant you failed to notice it- if you didn't write HR RRR S1 and S2 noted, then you didn't assess heart sounds properly. In other words, 'if it wasn't written it wasn't done'. My co-workers insisted I was working myself to death trying to include EVERYTHING. Charting by exception for us means if it's a normal finding upon assessment then you don't have to address it in the progress note. Any abnormal finding should be noted (ie lungs with bilateral I & E wheezes).
You also learn to narrow your focus depending on what the pt Dx is... you might not even write anything regarding bowel sounds in a pt on a regular diet hospitalized with COPD but would write several lines on lungs sounds, respirations, O2 Sat etc. I have to admit charting a book on every patient is a hard habit to break. I still find myself doing it sometimes, but when you have 7+ patients you learn to omit every word you can after you've had to stay 2hrs late following a 12hr shift to get your charting done a couple of times!