Progress notes/ Clinical file

  1. G'Day Rehab Nurses around the world

    Does anyone know of any documentation guidelines. eg what should nurses be writing in there notes at the end of their shift. On a recent audit I discovered that each nurse writes their clinical notes in different ways. Some OK and some not so OK. Overall they didnt tell much.

    Any ideas would be more than appreciated.

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    About Rehabme

    Joined: Apr '08; Posts: 31; Likes: 3


  3. by   mom2cka
    We chart both in a SPEADO format (skin, pain, elimination, activity, diet and other) and to the FIM - therefore, a basic nursing note, including addressing abnormals, and include specifics regarding the FIM support (although we're trying to revamp to document elsewhere for the FIM) - we are an acute rehab unit and chart differently from the rest of the units in the hospital. Some nurses write almost in an outline format, others prefer a narrative note. It was hammered into us in school to chart short and sweet, include only what you needed - then I started in rehab and learned to be a bit more elaborative in my charting. Hope that helps!