Can any nurses help me with documentation? I'm a nursing student.

ACute RN · Feb 13, 2011

I would imagine the documentation ?'s are going to test your knowledge of how to document assessment findings. Just remember keep it as objective as possible and do not make assumptions, such as "patient is depressed"... if you do need to write something subjective, please make sure to document the patient's statement - patient states "I have been very depressed lately". Also FYI, some instructors want to know that you can document your assessment findings in a professional manner, so instead of describing a patient as "blue" you would use the term "cyanotic". Hope this helps!

highlandlass1592, BSN, RN · Feb 13, 2011

I would agree that discussions would take place about how to chart what your physical assessment reveals. Every facility has different ways of having nurses document their assessment. I don't think you need to worry about forms as much as being concerned about using proper terminology.

As someone else pointed out, using the term cyanotic versus blue when describing pallor. You should actually have learned this terminology as you learned how to complete a physical assessment. It shouldn't be as hard as you think.

Neats, BSN · Feb 13, 2011

nursing schools teach documentation every step of the way, we just document as we go along.

there are different types of documentation and how to organize that documentation. the most popular by far is the soap method. if you use this method with all your nursing experiences you should be fine. s stands for subjective...what the patient is telling you, o is objective...what you see, like skin is dry and flaky remember only the facts. a is for assessment...this is where you would document perhaps a nursing diagnosis related to the skin and finally p is for plan what you will do...refer to provider or use nursing protocols and provide some type of skin cream.

this allnurses forum has a wealth of documentation info and examples. you need to practice your documentation.

lastly i use the soap and what is called sbar to communicate orally and written. sbar is situation, background, assessment, response, much like a soap note but very brief, just the facts. it works best in a fast paced environment.

tokidokifantasy · Feb 14, 2011

I think for physical assessment test, you need to verbalize to the teacher on how you would document your findings.

For an example, if you assess the abdomen , you are looking for masses, distention, tenderness, and sounds, so after you complete the assessment, you would verbalize to the teacher that " abdomen flat, no distention, no tenderness. Bowel sounds are active on all four quadrant."

Every teacher is different, some instructors don't like you using too many "no..no" , but my instructor is ok with it.

BrookeeLou_RN · Feb 14, 2011

This may be old.. but I think a good standby is the "head to toe assessment" This gives you a plan to follow in your head. It makes it hard to forget a system and makes your assessment organized. Documenting following this can be narrative or SOAP or any of the others you might learn. I have found using narrative charting was used for most places I have been.

Kooky Korky, BSN, RN · Feb 14, 2011

well, this is a tough question since i don't know what your instructor has said about it. but you don't either, so we are both confused.

in general, whatever you chart should be

true;

free of your emotions,

free of hearsay, (such as, the patient and family drove you crazy - that does not get charted. or, the day nurse reports to you that the patient had a fight with dr. green. leave that out. let the doctor chart it if he or she wants to. if the patient mentions it to you, you still don't have to chart this controversial item. or you can say "pt. says she had a quarrel this morning and has had a frontal 5/10 on pain scale headache since then." then chart what you did to help alleviate it.)

objective (what you see, feel, hear, smell)

quoted (pt said "i have soreness here - points to ruq of abdomen") this is known also as subjective.

i think instructors want you to be thorough. in real life, once you are working as a nurse, be brief. a lot of times, the less said, the better.

i'm a little surprised that this is considered 1st semester work. usually, they are teaching baths, bedmaking, vs, foley's, medical terminology, nutrition, sanitation, and other basics at this point. well, i guess things change.

i wish i could be more helpful. please get with your classmates.

some places teach a certain format for charting. like soap or soapier or pomr.

s= subjective = what does the pt say about her post-op pain?

o= what do you observe about the wound, is she grimacing, sweating, etc.

a = what is your assessment? post-op pain, of course

p= what did you do about it, what was or is your plan?

i = intervention = how did you intervene? med, positioning, etc.

e = evaluation = how did the intervention work?

r = re-assessment; if it worked, great, check on pt in 30 minutes; if still in pain, try massage, guided imagery, whatever, call md if no relief or insufficient relief in an hour;

problem-oriented medical record = there is a list of problems and the charting addresses one or more of them; example: asthma, diabetes type 2, post-op day 1, death of spouse last week, son in jail; whatever;

charting by exception = don't chart unless there is a problem; used a lot in long-term care;

there are others i imagine.

here's how we used to chart on the telemetry floor: alert and oriented x3; skin warm and dry, no cyanosis; resp even , full, unlabored, rate 18 per minute; lungs without wheezes, rhonchi; no stridor; moves all extremities; taking meds, resting between therapy, care, etc. ; wife at bedside; wheels locked; bedside table, call bell, kleenex, tv remote, water, urinal within reach of patient;

mercuryrawks · Feb 14, 2011

I am in school still, but our testing on documentation in nursing 1 was more about the legal implications, if you didnt doc it, it wasn't done. That you can call in late entries, but the nurse who writes it has to doc it as a late entry. um...nothing vague. nothing that could be twisted around. Keep it short and direct. Good luck!

AgentBeast, MSN, RN · Feb 14, 2011

You'll likely be asked NCLEX style questions.

A nurse is taking blood pressure and hears the first Korotkoff sound at 200mmHg, the sounds disappear at 160mmHg and reappear at 152mmHg then fade away and are no longer audible at 100mmHg. How would the nurse document BP.

A. 200/100

B. 200/160/152/100

C. 160/100

D. 200/152/100

brielle776 · Feb 14, 2011

You'll likely be asked NCLEX style questions.
A nurse is taking blood pressure and hears the first Korotkoff sound at 200mmHg, the sounds disappear at 160mmHg and reappear at 152mmHg then fade away and are no longer audible at 100mmHg. How would the nurse document BP.
A. 200/100
B. 200/160/152/100
C. 160/100
D. 200/152/100

I'm in my first semester of nursing school too, and just wondering how would that be documented?

AgentBeast, MSN, RN · Feb 14, 2011

I'm in my first semester of nursing school too, and just wondering how would that be documented?

A. 200/100