books to help with better charting

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Specializes in Home Care, Peds, Public Health, DD Health.

I have been working in home care now a few months and writing notes is a large part of my job. I feel as though there is always a much better way to write what I am doing. I started looking at books and there are a bunch of charting books, charting made easy etc. but what I really want is something that gives good explanations of ways to write things in more "nursing" terms. for instance writing "recieved client in bed laying in supine position. Patient shows no signs of distress" instead of " I got there and she was on her back in bed and looked really good, she was happy and watching tv. Make sense? I know there are things that I can write a lot better that I havent learned yet or just dont remember all the terms. If anyone has actually read any of these books or used them as a reference, I would really appreciate the feedback. Thank you!

angels mommy

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Specializes in Emergency Nursing.

I use the "Nursing Made Easy" series and there is a book specifically on charting. I am also going to buy a charting book from Amazon that I just found (the name escapes me at the moment) but if you just go to Amazon and type in keywords like "Nursing" and "Charting" I'm sure you will be able to find something. Good luck!

!Chris :specs:

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I have the same problem, I find that we do not see any one else's notes very often as hospital nurses do. I often find myself struggling for the right terminology when writing notes. Hope someone has some good ideas I have the Incredibly Easy book and another whose title escapes me at present, but they are not really all that helpful.

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Specializes in Home Care, Peds, Public Health, DD Health.

i just ordered 2 books, I will let you know if they are helpful at all. I got them from amazon.

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Specializes in Emergency Nursing.

I'm looking at "Chart Smart: The A to Z Guide to Better Nursing Documentation" By: Springhouse. There seems to be some pretty favorable reviews for it so I think I'm going to get it.

!Chris :specs:

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Specializes in Home Care, Peds, Public Health, DD Health.

can you let us know what you think about the book? I also ordered two books. it would be great if everyone that orders books gives a nice little review of what the books covered and didnt cover etc. that way for future reference, others will be able to look back and see our post. thanks in advance, I will wait to read your future post!

angels mommy

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