Anyone have good resources for charting?

[shell1206]

Hi- I am a new graduate and have been working midnites for five months on a busy med/surg floor. I am really liking my first job however at times I feel that I am totally lacking in the charting department. At times I feel like I am putting too much information and at others not enough. I look at other nurse's notes and they seem to also either fall into the same categories -- too much, not enough or in some cases none.

We use computer charting which allows us to document the patients assessment by system (skin, cardiovascular, neuro, etc) and then we can also use 'nursing progress notes' to put in more detail for the next nurse taking over or to document calls to doctors/orders given. Most nurses put a progress note in on each patient at beginning of shift giving a short synopsis of their current condition.

Does ayone have any good reference books that they've used to help them become better at documenting and also on covering against any liability?

Thanks!

Shell :)

[SummerGarden, BSN, MSN, RN]

there have been good threads on this topic already. type in “books” and “charting” to locate a few. here is one:

https://allnurses.com/general-nursing-discussion/books-help-better-449568.html

[MikeyBSN]

Let me know if you find a good book on the subject, as I have never found any truly useful information. Let's face it, a major point of charting is for legal purposes. Although we want good continued care for our patient, our documentation helps protect you in court. You will hear this over and over from nursing professors. What you will not hear, and what you have so accurately pointed out, is that no one will teach you how to document. Why? IMO, because many nurses and professors simply do not know or cannot agree on the best way to document. As a person with a fundamental and independent deep interest in law, I can tell you that my documentation has changed considerably over the years. I have also been to "documentation classes" taught by LNCs and other nurses with little to zero legal background, and some of the advice they give has been, in my opinion, terrible. Personally, I have seriously considered writing a book on the subject, because there seems to be no decent documentation book for nurses in existence. Perhaps there is and I have not read it yet, but I have not been impressed with the classes I have experienced. I have become a little more jaded over the years and actually unofficially "written nurses up" for god-awful documentation. And let me just make a quick comment on computer documentation: there are a lot of pros an cons to the automatic system. Every day I have to clarify something in the progress note because clicking a box on the assessment screen either does not give the whole story, or gives a plainly inaccurate story.

My down and dirty advice would be to document what the patient tells you, and use quotation marks for this. Then document what you see, what you hear, what you smell and what you feel. Make sure your note tells a story. Why is this person here? What happened to them at home? What did they do in the ED? What is the plan? It's too difficult to explain in one post, but basically you want to convey useful information to the next provider, and at the same time protect yourself from a cross-examination in court. I hate to say that most documentation that I see on a daily basis would utterly fail in this endeavor. If you write some spectacular nonsense like "+ETOH" in an assessment, you better have some answers when your patient dies of hypoglycemia and a blood sugar of 22. You better be able to explain on the stand what "+ETOH" means. Did you smell alcohol? That's funny, because grain alcohol has no odor. Did the patient appear drunk? You do know that hypoglycemia and a variety of other conditions cause intoxication-like symptoms don't you? Did the patient say he was drinking? I don't see any direct quotes in your note. Did EMS say he was drunk? How do they know and where in your note does it say that EMS told you anything? I could go on for a while, but the point is that documentation is important, and there are very few good resources on the subject. So when you document just keep in the back of your mind the notion that you might have to defend this one day. Are you prepared to do that?

[lckrn2pa]

There's no substitution for experience. Charting will come as you gain experience and as long as you do the computer based charting required by your hospital you'll do fine. Follow your hospital protocol's and standards and don't deviate from them because that's when you leave yourself open. I've worked with setting up computer based charting at a couple hospitals back in the day (I've been doing this almost 20yrs) when it was just really getting geared up to what it is now and those templates are set up to hit everything you need to address when assessing your patient. Don't use unapproved abbreviations nor make assumptions you things will go just fine because the computer charting assessments will have you covered. Hospitals spend thousands on these things to keep themselves out of law suits.

[shell1206]

Thank you so much for your replies. I ended up buying 'nursing notes the easy way, 2nd edition' on ebay. It got some good recommendations for charting help. I'll let you know how helpful it is when it arrives next week.

Shelly :)