How do your start your day on paper that is.

caliotter3 · Nov 15, 2011

I write that I arrived and the patient arrived because we arrive at different times when the patient goes to school. On days pt. is in school, "Reported for duty. ....", then when the pt. gets off the school bus, "Arrived home transported on school bus. Transferred to room ....." On days I meet the pt., "Received ....." I never get greeted by anyone any more, so I don't have to say that, most of the time.

systoly · Nov 15, 2011

First, I document if I received report and if so from whom or if it was a written report, (because often I do not get a report and four hours later it's something like,"oh, I forgot to tell you...") followed by a quick visual assessment of the patient including activity and any signs of discomfort.

ventmommy · Nov 16, 2011

I think "arrived at pt's home" is kind of pointless. If you hadn't arrived, you wouldn't be writing the narrative :)

Looking through our binder most are "Assumed care at (time) from Mom. Report received (some enter a brief synopsis here) from Mom." Some are "received patient from mom."

I guess it might matter who greets you and gives you the report if your patient is the subject of a custody dispute, impending divorce or is receiving in-home services from DSS to prevent removal.

tothepointeLVN, LVN · Nov 16, 2011

Yeah I agree writing arrived IS pointless I just wanted to know why others did it. LOL

Though I guess with hospice describing the initial interaction with the family can be useful in terms of assessment and invention of families reactions but if you just state "arrived" whats the point.

So am I safe to revert to my previous received pt + report? I'm pedantic about my narritives.

SDALPN · Nov 18, 2011

I always have thought arrived at patients home is pointless. The only time I have used that is when I was transporting a patient from school to home (back when that was allowed).

I start my notes with 00:00 Received report from (nurses name, parents name). No changes reported (or I document any changes or requests). Pt awake and secured in (w/c, bed, stander, etc). NAD noted. (for vents) Vent settings checked and verified with orders. Trach ties secure. TF infusing @ #ml/hr without difficulty via GT/JT. Rails up x2 (if in bed/crib). AFO's on/off. HME/humidifier on/off. O2 via trach @ 2LPM. Diaper wet/dry (and document changed diaper if wet). Pts activity. Pulse ox probe on L foot/rotated to X site.

00:05 Assessment completed as documented on flow sheet (or wherever you document your assessment at). VSS (or whatever applies). Anything I can't document on the assessment flow sheet goes in to my notes.

00:30 Start of shift tasks completed. (equip. cleaning, changing sxn caths, etc which are documented on some other flow sheet)

If I don't receive report for whatever reason, I'll document 00:00 unable to receive report. And go right in to what I see at that point.

If I walk in to the room and it smells strongly of urine I will document it or any other environment related issues. I have one case where I don't think the family is changing the diaper. So in the morning I will go in and the room will smell of urine and the diaper is falling apart.

I don't document who is home (I've seen different arguments on that). But I will document when I parent comes home from work. That way it shows the ins. company who reviews notes for hours that the parents need the hours because they are away at work. If I work for a parent that doesn't work and sits around ordering me I'll make an exception and document that they are home.

If meds are due when I arrive I'll also document meds give via route and if its via tube I'll write tube flushes easily to show patency.

Then the rest of my charting is easy because everything observed has been documented.

Kyasi · Nov 18, 2011

I always started with, "On duty, report received from Dad. Child is asleep with Pediasure feeding infusing at 100cc/hr/pump via GB. Assessment completed, vent check done." I did not repeat my assessment in my narrative because it is already on my assessment sheet along w/vital signs. I know from our state audits that the condition the patient was in when you arrived and when you left is very important and also who you reported off to. I always spelled out exactly how I left my patient. "Client is secured in w/c watching a video, smiling and in no apparent distress. Pediasure feeding infusing at 100cc/hr/pump/GB. Tvent on over trach, respirations are regular/nonlabored, biox 94%, diaper dry. Report given to Mom, off duty. I also made sure I had a head to toe assessment done just prior to my leaving.

SDALPN · Nov 18, 2011

Kyasi, why document "on duty". Isn't that obvious since you are charting? Also, once you receive report you've legally accepted the assignment.

dirtyhippiegirl, BSN, RN · Nov 19, 2011

I picked up the habit of writing "arrived for shift, received report from X" from reading through other nurse reports, although I also logically KNOW that the first half is redundant.

I've also noticed that the longer I stay on a case, the less descriptive I tend to be. I have one case in particular which I do a lot of pt/ot with. At first, I was documenting times and exactly what we did. Now I just end my note with "worked on xy,z throughout day."

tothepointeLVN, LVN · Nov 19, 2011

I think my charting is getting longer and longer the more I know. Granted I AM doing home hospice shifts which tend to have more assessment/interventions and I am charting a lot more psychosocial stuff.

But BOY do my wrists hurt and my ballpoint pen budget is through the roof lol

But when I PDN my day would be exactly one page no matter what and somewhere a long the line the forms changed so there was less lines so I wrote less.

Kyasi · Nov 19, 2011

Kyasi, why document "on duty". Isn't that obvious since you are charting? Also, once you receive report you've legally accepted the assignment.

Because that was how the agency I worked for wanted us to chart. We were to begin with 'On Duty' and end with 'Off duty'.

tothepointeLVN, LVN · Nov 19, 2011

I always end with a set of vitals when I leave so that way I can document that patient was alive and well when I left. I guess with my agency or at least the story they told me when I was hired was they had a nurse that ended her charting with "took out trash" and there was a gap in coverage where the mom was assuming care and mom made a mistake and the child passed but mom insisted the nurse left a dead child behind.

I sometimes document left house/end of shift but only in cases where the patient has passed ( hospice ) and the mortuary has picked up and the family is ok since there is no one to sign off care to.