I try to see my patients every hour but how do I make my nursing notes sound good if the patient is just resting in bed?
What can I say about them that would make my nursing notes excellent?
Mar 3, '13
Pt resting quietly in bed. Respirations even, unlabored. Pt rouses to verbal stimuli.
Mar 3, '13
You can't possibly chart on them every hour (?), especially if you work nights and they are in bed asleep. I like the above answer as well as:
...call light in reach
...skin warm and dry
...no c/o voiced
...no distress noted
...resting with eyes closed, resp. easy.
Also, take a look at what the other nurses chart over the time frame of the same shift you are on.
Mar 3, '13
I've been working in an acute rehab hospital for the past three years and the nursing staff is not expected to chart on them hourly.
If nothing eventful is happening, I chart:
Patient resting comfortably in bed with no s/s of acute distress observed at this time. Respirations regular and unlabored. Call light and personal items within reach. Staff will continue to observe PRN. Half rails up x2. Safety measures in place.
Mar 12, '13
A few years ago, I worked in a rehab hospital. A few of my fellow co-workers would make notes at breakfast, lunch, and dinner, that said nothing more than, "call light in reach...eating meals EOB..etc.". They said that they didn't want to be blamed if "something went wrong". I'm indifferent. I think these generic comments are important, but not in multiple, small notes. I'd rather have one detailed note, unless there was a change in condition/behavior.
Mar 16, '13
We right one note at the end of the shift, in addition to our FIM documentation. The shift note summarizes patient education, safety, therapy carry over, medical concerns, etc. Things that justify the need for 24-hour rehab nursing. So... think of an auditor reviewing the note for appropriateness and if your note says - call light within reach, no problems, etc... they'll say - why did this patient need acute rehab? What did you do differently than could be done by a CNA/PCA in a nursing home or subacute setting? Include that in your note and you'll be well covered for the medical necessity argument.
Apr 1, '13
We only do physical assessment chart, FIM score and some routine stuffs. But checking hourly? We just check a paper inside the room hourly and thats considered the notes. It includes signature, what is the patient doing such as b= bed s=sitting etc.
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