Charting Help

[kherd14]

So, I have been doing private duty/home health for about a month now and I'm struggling with charting. After he goes to bed, there isn't much to chart. He's on a vent at night, and he's hooked up to a pulse ox; he requires brief checks, I reposition him every two hours, I vent his Gtube every two hours, and he gets vented rectally once every shift. Also, he gets a nightly feeding that infuses throughout the night. Basically, I don't want my charting to sound repetitive, but I also want to have detailed notes.

Here is an example: Vented Gtube to release excess air with success. Void noted and pericare given. Pt repositioned for comfort. Pt remains stable and is resting on his side with eyes closed. Respirations are even and unlabored. Patient is arousable upon calling. No distress noted at this time. Nighttime care ongoing. No further concerns as of present. Patient has no other needs at this time.

[toomuchbaloney]

I would recommend that you chat in the way your employer outlined in your on-boarding. With stable vented patients it was my experience that an assessment was completed and documented at start of shift and then deviations from that baseline were noted.