Charting format

jackiemc08. . .i think that you will find many examples of check off assessments in the care plan books of carpenito. i've seen the critical pathways charting forms in carpenito's books as well as assessment forms that she has designed. while i have not seen carpenito's recent forms, i would venture to guess that they are designed to be merged with nursing diagnoses since carpenito has been an active member of nanda for many years. doenges has been very detailed in her care plan books in listing out assessment items that should be addressed for various types of patients. while they are not check off items, her's are simple short fill in answers. her adult medical/surgical assessment tool is organized by the diagnostic divisions that nanda has grouped the nursing diagnoses into, so it is also meant to be merged with nursing diagnoses. (nursing process is assess first and then choose nursing diagnoses from abnormal data obtained during data collection.) i have doenges' med/surg and maternity care plan books and she has assessment tools that are organized this way in both these books. the difference is that in the maternity care plan book, the assessment tools have items in them that are specifically tailored to the maternity patient. another place you might be able to get a look at some hospital forms that they let the public have free access to is on the hospital soup site. here's a link:

http://www.4nursingmanagers.com/policies/rn/asp/id.22/pt/viewincat.htm - a list of some of the categories of forms that the site has available for free to the public. there are some nursing assessment forms available here that you can access.

http://connection.lww.com/products/carpenito10e/documents/sampleadmissiondatabase.doc - an example of one of carpenito's admission assessment forms. i can't get access to the other sample forms that are online.

i also have a number of links to assessment guidelines or forms from some of the various nursing schools around the country. these, however, were never designed to be hospital forms. they were developed by nursing instructors or nursing programs to assist students in learning how to complete a nursing assessment. i would be more than glad to go through my links and make a list of them for you if you want to see what is there.

i have been studying health information management. i recall one of my instructors telling us that forms design is often something that is also managed or facilitated through the medical records, or health information management, department in order to assure continuity of all the forms being used in the patient chart. so, i would suggest that you ask if someone has given medical records, or health information management, a heads up that nursing is wanting a new form designed. the medical records, or health information management, staff might have access to samples of charting forms through their professional memberships in the american health information management association or other groups. i'm sad to say that i am also a member of ahima, but i'm not very proficient at navigating around their website although i will attempt to see if i can find any access to forms on there for you.