Charting

  1. My charting leaves a lot to be desired, I'm afraid I feel I sometimes type too much and others too little and while I try to chart very professionally (and with the correct nursing jargon) sometimes I just type normally Do any of you have a generic paragraph you use for your most common complaints?? I'm considering creating one that I can copy and paste into student records for my most common complaints (i.e.: stomach/headaches, scraped limb, ice pack etc.) since I end up typing pretty much the same thing (and performing the same interventions) for every encounter. Obviously I'd "tweak" it for each student as needed, but I feel this might save me a little bit of time and will be more consistent in my charting.

    Is that a thing or am I just being lazy??
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  2. 8 Comments

  3. by   JenTheSchoolRN
    I'd love to say I use all the proper nurse jargon, but I don't always. Folks who are looking at my charting are not medical folks.

    And yes, I have shortcuts - they are time-saving. I do tweak them for students. I can also modify my drop downs in my EMR, so I have done this to help with charting the simple visits - i.e. needed to use bathroom.
  4. by   ruby_jane
    My favorite non-nursing boss (this is my second career) said: Don't put anything in writing that you wouldn't want to see on the front page of the Seattle Times.

    My favorite nursing prof told us to imagine our charting blown up on a screen in front of a jury. Both are correct. I waaaaay overchart because of them.

    At a minimum my understanding is we have to chart assessment, what we did, if there was pain, was the pain improved, and how the situation was resolved.

    Here's my template (we use Skyward):

    Assessment findings: Student presented (for whatever) List any subjective findings here, like they had or didn't eat, told or didn't tell parent, and my favorite - how long (" of five days' duration).

    Chart their color, vitals (and anything outside normal demands a reassessment), anything like the fact that they're doubled over with stomach pain but then also waving at friends in the hall.


    I : Intervention, Temp (O), what I did, what I saw, referrals I made.


    Student requested or denied a call to parent for symptom management.

    E - Student returned to class in no acute distress, with instructions to return to clinic if symptoms worsen. Student verbalized no complaints about treatment.

    If it's just a check off for medication, I have a template: Student tolerated without complaint.

    If it's hygiene supplies/band aid/contact lens care or anything the student does for him/herself: Student self-care, student returned to class in no acute distress.

    My overcharting helps me when a parent calls and wants to know why I "didn't do anything" for sweet baby. Your student declined a call to you, declined rest in the clinic, left in no acute distress...and then called you on his phone.....
  5. by   OyWithThePoodles
    I try to keep it as simple as possible unless it is a kid with a crazy parent.

    Generalized stomachache, no nausea or vomiting. Student reports (not) having breakfast (offered breakfast), encouraged student to attempt a bm. Temp ***. (If pale, will chart). Mint given. (Rested if they did). Told student to return if symptoms worsen. (If pain is localized, will chart that)

    C/o h/a, temp *** has not had breakfast, snack given. Rested. (Yesterday had kiddo reading while c/o h/a, I charted that they were reading)

    If I speak to someone from home I try to put their name, if they are a problem parent I might add the gist of the convo.
  6. by   NurseBeans
    I totally have a word document on my computer with pre-written notes. There isn't any other way for me to get documentation done. I don't use them for every single kid, but I was finding myself typing the same things over and over. I tweak prn, and honestly I like knowing that my documentation is complete when I use the pre-written template.

    I mean, I see about 10 headaches a day, I do the same thing for 9 of the 10. If I can copy and paste my 3-sentence note it saves me time and frustration. I don't consider myself lazy, as I only like to save time so I can do more work
  7. by   Truth_be-told
    I just love medicare charting. It's like the government doesn't want to put out any money for sick, disabled, or dying people (yet they have no shortage of funds for warfare and death) so they make us write a thousand word essay as punishment, under the rationale in typical government fashion that the quality of care can be proven by increasing the quantity of paperwork. The result of course is the exact opposite. The more time you waste clippity clipping on a computer means less hands on care and less time on the floor. Being 220 trillion in actual debt, I wonder if they will still demand all this meticulous charting after they steal our medicare and social security to pay for their never ending oil wars? I am betting they will still l find a way to make healthcare less effective, like everything else the government gets its hands on. Just wait and see.
  8. by   MrNurse(x2)
    Quote from Truth_be-told
    I just love medicare charting. It's like the government doesn't want to put out any money for sick, disabled, or dying people (yet they have no shortage of funds for warfare and death) so they make us write a thousand word essay as punishment, under the rationale in typical government fashion that the quality of care can be proven by increasing the quantity of paperwork. The result of course is the exact opposite. The more time you waste clippity clipping on a computer means less hands on care and less time on the floor. Being 220 trillion in actual debt, I wonder if they will still demand all this meticulous charting after they steal our medicare and social security to pay for their never ending oil wars? I am betting they will still l find a way to make healthcare less effective, like everything else the government gets its hands on. Just wait and see.
    This rant did not address one issue the OP brought up. This forum is unique in that we are isolated at work, this is our nurses' station. We need real time responses and are pretty on point. I could counter most of what you said, but it is not appropriate in light of what this forum is. Thanks for stopping by and feel free to comment, but please remember the uniqueness of this area and act like you are a guest in another unit's nurses' station. Peace.
  9. by   Amethya
    Ours is Skyward too:

    Visit reason: Different selections. "EPX- Epistaxis (Nosebleed)
    Visit treatment: Ice and cotton roll
    Visit disposition: RC (Return to class) and parent contact, LVM
    Examined by: [Amethya]

    Notification: Time, name of parent, method, result and comment (I put informed parent/mother/father) This one was Left voice mail because I left one.

    Comments: I put anything, like this one will be c/o epistaxis (nosebleed). Mild bleeding. Ice pack and cotton roll x 15 mins. Informed mother, return to class.

    I always call parents for EVERYTHING. (CYA especially because I'm not an RN.)
  10. by   ctate
    Just happened. Had Little Darling I know to have history of headaches and is waiting for further testing come in for meds. In these cases after the initial reported charting I will just do the simple drop downs on Skyward. However, this LD has been known to not give all information asked for, so in the Notes area I reported she said she did not take meds at home.

    I tend to write what seems like books sometimes on what seems simple, just because some of my High School LD's tell me one story and mom/teacher/administrator another or not at all. And I do have times when the parent's report tend not to be the same as what LD tell me they said. I was told when I first started to watch myself in the that area and to remember, if its not charted, it was done or said.

    I use nursing jargon at times. It wasn't until we started computer charting that I noticed I use the word "that" a lot. So, I do proof read my charting to make sure it's not exactly how I talk. A mix of Texan and Oklahoman language would not translate well in a court of law.

    CYA is my favorite safe guard. I never really thought to have copy and paste charting for ease.

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