Charting in Clinical Notes

Our software has screens for each of the body systems - so we do a head to toe every visit on every patient. I don't mind seeing/using the check off blocks for things that are normal. But, I do chart and like to see more detailed charting on anything abnormal (lung sounds, edema, etc) and especially the reason we are caring for the patient- example -- wound description - should have description of wound, care provided, response to treatment, etc. You should be able to read the visit note and have a clear picture of the patient, their condition and what care we are providing...even if you have received no report.

What software do you use?

Hi HH nurses,

What do you look for in the clinical notes from other nurses? What do YOU like to see?

Thanks so much!

In handwritten notes, definitely penmanship. What good is it to have a note that no one can read (including the writer at times)? I should always see teaching to at least one of the interventions/goals listed on the 485 and the patient's/caregiver's response.

A complete assessment, whether it's check-off boxes or handwritten. Complete vital signs. Pain assessment. More detail on anything that was abnormal, such as lung sounds, heart tones, edema, altered mental status. Presence/absence of caregiver. What the nurse did/taught in detail. I don't want to see "wound care performed."

If I were going to write a complete narrative note, assuming no check boxes, it would look something like this:

Pt sitting up in hospital bed in home, no acute distress observed. Alert and oriented to self only, denies pain at this time. Daughter Penelope present for assessment, states" pressure ulcer is getting worse." Heart rate and rhythm regular, lungs clear to auscultation but difficult to assess as patient unable to cooperate with instructions to breathe deeply. Abdomen soft, non-tender with + bowel sounds x4 quads. Last BM (date). Pt incontinent of urine, undergarment clean/dry at this time. Pedal pulses palpable, no edema. Stage III pressure ulcer to coccyx cleansed with wound cleanser and gauze, packed with hydrofiber dressing, covered with ABD pad, secured with tape. Caregiver instructed on wound care technique but states, "I don't think I can do this every day." Wound beefy red with smooth margins, periwound skin macerated to 1 cm border. Old dressing with green-tinged serous drainage with foul odor. Voice mail message left for Dr. Smith's MA re: wound appearance, awaiting new orders. Caregiver instructed on positioning and mechanical off-loading techniques, increasing protein and vitamin C intake for wound healing. Handouts left in home folder for caregiver's reference: "Diet for Wound Healing" and "How to Prevent Pressure Ulcers."

Hope that helps.

What software do you use?

Allegheny...overall pretty good