Charting Help Please

The one hospital we do clinicals at does the old fashioned charting. The other place does computer charting. My problem is the wording. I know it eill get easier but it just isn't right now.

I think your best help will come from your instructors and from reading other nurses' charting when you do clinicals.

There are also books about the best (safest) way to document and they will help you cover all the bases. Lippincott's Manual of Nursing and other clinical companions tell you what to chart for each dx, which is very helpful. You can buy some of these online, but best bet would be to hike over to your nearest bookstore and actually look at them for readability and practicality.

Here are a few websites that might help:

Lippincott's Manual Of Nursing Clinical Companion is great because it clues you in to what to assess and what to document. *There's also a big one that I use for reference but you can't carry it around with you.*

http://www.lww.com/product/?0-7817-3694-3

Charting Made Incredibly Easy! is probably the best to read at home:

http://www.amazon.com/exec/obidos/tg/detail/-/1582551642/qid=1122764153/sr=8-3/ref=sr_8_xs_ap_i2_xgl14/002-1290352-3520057?v=glance&s=books&n=507846

those suggestions above are excellent. There are lots of good charting "how to" books and charting (for legal defensibility) conferences/classes out there. I suggest you look into these, for more help. Good luck!

i tried to post this earlier but i think the site was down, so i saved it.. I hope it helps...

Here is a model that I recieved while I was in nursing school. You have to plug in your own information. The stuff inside the is a 2nd option.. You will see what im talking about once you start writing.. This is a long example of charting. It will be much shorter once your out.. However this is good to cover yourself while in school.. I HOPE IT HELPS YOU AS IT DID ME...

-David

00/00/0000

0800:

98.6,82,20,120/80 Skin pale, warm & dry. Turgor fair. Alert & oriented x 3. Cheerful, follows command, PERRLA. Maintains eye contact, speech clear. Resp's. even & unlabored. Bilat. Lung fields clear to auscultation. o2 @ 2L/min. via n/c in place. Apical pulse regular rate & rhythm. Radial pulse strong & regular. Bilat. lower extremities warm to touch, pink, acyanotic. 2+ pitting edema bilat. ____________. Abdomen soft, nondistended with audible bowel sounds _________. G-tube site without drainage, patent & intact. Full strength "choice" infusing via pump @ 55 cc/hr. Voiding quantity sufficient, up to BSC with assist, urine dark yellow without sediment or mucous. I.V. site R. forearm dry & intact. D5 1/2 N.S. with 20 mEq. KCL infusing @ 125 cc/hr via pump. Stage sacral decubitus covered, duoderm dressing dry & intact. Denies pain; level 0. Resting comfortably L. side. Side rails up as per order. Call light within reach.---------------------------------------------------Nurse Student S.P.N. / Nurse Instructor R.N.

heres an easy tip. i know as a student you might not know all the terms, but always think of charting as telling a story. start the charting off with what you see. usually youll always greet the patient so its gonna be their loc. and after you chart down what you see, you chart on what you did, whether its patient teach, administering meds and how they tolerated, or performing a procedure.

remember, its what you see and then what you did.

Assessments aren't much trouble. The main thing is not to forget charting anything important. My memory is terrible, so I carry a tiny notepad into the room and scribble as I go.

Having a routine is also important. You might want to begin with a room scan (what the pt's doing, visitors, environmental hazards), then mentation as you introduce yourself and the pt responds, then all tubes going in and out of the pt, all while you ask your questions about CP, SOB, etc. Then cap refill and fine motor control (holding a hand is reassuring), and only then go head to toe. Chart in the exact same order you assess.

Interventions can bite you if you don't checklist your charting against the DAR format. First you give data (1130 - Fever - Temp 103.2) then action (1137 - Fever - Gave PRN med, see MAR) then response (1230 - Fever - Temp 99.1). Some entries may contain all 3 parts. Others have to be broken up. But all 3 parts should be there unless you handed it off totally, say you called and nothing happened (Dr informed, no new orders) or you turned over care to the oncoming shift.

The reason I mention interventions is when you chart your assessment, you are going to generate a lot of D items that will need to be followed up with A and R items.