Nurses General Nursing
Published Oct 24, 2013
I'm a "new" nurse and I feel like when I do chart it isn't "enough". What tips can you seasoned nurse give me. I feel like I'm not getting all my wording or I'm not charting "enough". Examples will be GREATLY appreciated. Thank you.
lisajtrn
70 Posts
I remember being told many years ago that the word "appears" should never be found in a patient note. State the facts. Rather than saying appears to be comfortable, state the facts, i.e.: resting in bed, eyes closed, reading, no facial grimacing etc......