Another charting question

[stepaukob]

This question is in regards to charting things that are essential.

For instance, in one facility I worked we had places to chart in the computer for anyone on anticoagulants as to whether or not there was bleeding of the gums, etc.

How much of charting is hospital policy vs JACHO requirements? Could someone put up a list as the essentials of charting when traveling?

I'm also wondering if you don't find a place in the computer, do most people try to incorporate this info into a written note to cover your a**? Thanks for any info.

[9309]

Regarding a written note-

In some sysems there is a place for "comments" which could be used to cover anything not covered elsewhere.

As far as CYA with a written note, it may or may not. If the information is documented elswhere,a note won't help in any way. In other words, if you are charting by exeption, and have checked that respiratory is WNL, writing that pt is breathing easily at a rate of 16, LSCTA, no SOB or DOE doesn't add anything.

A narrative note should only cover issues not adressed elsewhere.

Just my humble opinion.

9309

[amy0123, BSN, RN]

I agree with above poster. Usually there is a note section or tab within the electronic charting. If there is something not WNL then a more detailed note would be added along with the interventions that resolved it. I would not write a detailed note on normal observations.

The note tab should be revealed during orientation on the floor. If not then ask your preceptor/ resource/ charge nurse how they would enter a note.

I was told on one orientation that the computer charting was created by the company that designed it, the facility's protocols (JCAHO standards, etc.) and own staff input. I assume that every hospital's computer charting pertains to their own policy.

[Daytonite, BSN, RN]

if a certain hospital has a policy to chart something a specific way, then that is what you have to do. for your own protection you can always make a narrative note to clarify something. my test is to ask myself if i came back to read this chart in 5 years would i get the complete picture? if not, then i make a narrative note. that narrative note protects me more than the hospital. the heck with jcaho. they're not going to pay a court settlement if the patient sues. let the managers and administrators work out the jcaho compliance issues.

[stepaukob]

Thanks for all of the input.

I currently started at a different facility partly to see how I could function in a new facility. The tasks, meds, and general care were easy to pick up but the computer charting was difficult. The facility uses CIS and it took me a number of weeks to figure out all of the charting and I'm pretty good with computers. There is a traveler there and she did mention that this computer system was one of the more difficult she's come across. Thanks for all of the input, I guess it's a matter of just figuring out the charting as quick as you can.

[travelinjones]

My little narative note trick is to read it with "your honor" in front. Example:

(Your honor) The patient refused the scheduled (whatever med/tx) stating "It makes me howl at the moon and run around naked."

...actually had a sweet 80ish little old lady tell me that yesterday...and yes, we were talking about ativan...