charting help - ugh!

j621d · Jun 23, 2010

You are not writing the Great American Novel. You are documenting your findings, or that there has not been a change. You want to write something so that 5 years from now when you read it, you can be assured that what you wrote was what was happening (or not happening).

What happened with the patient since your last notation? Did they walk, go for a test, receive a prn med? You want it to be an update from your initial assessment.

when I first started out in nursing, I would read other notes to give me a clue as to what is important - but you will need to recognize in their notes if it was an important observation. You don't want to continue with notes that do not add anything. (Is this clear as mud?)

Lola77 · Jun 23, 2010

I think reading other people's notes is a great idea - just to get a feel for what to write. I feel like such an idiot. I guess that is what the first year of nursing is all about - feeling like an idiot until you get it :)

j621d · Jun 23, 2010

You are not an idiot. You are still in learning mode!

elizabeth321 · Jun 23, 2010

Report received. Patient awake on stretcher on initial rounds. Respirations clear and easy at 16 respirations per minute. Alert and orientated x 3. Patient stated slept poorly due to pain. Reports pain 4/10 sharp non radiating to right calf. Area red and warm to touch. Skin intact. Moving limb well and able to weight bear. Chest clear on auscultation with air entry equal bilaterally to bases no adventitious sounds heard. Same reported to doctor who examined patient. Orders received. Tylenol #3 two tablets at 0830 h. Morning care at bedside with setup assist. Am medications as ordered given. Colace one tablet PRN provided with extra fluids. Voiding in BR. States small BM formed. Took breakfast in part. To x-ray now via stretcher. Porter in attendance.

You get the general idea. You want to report your findings in a systematic way....I know some places have tick charts so you just chart the things that are eventful.....I also do vital signs on my initial check and would only chart on things that were unusual...if they had a temp, is their skin flushed are there membranes moist are they alert? If they are tachycardia and hypotensive are they SOB or confused....just try to go from head to toe and ABC with details about how they are ambulating, eating, engaging etc.

cherrybreeze, ADN, RN · Jun 23, 2010

You say your notes sound "nursey?" How should they sound? You're a nurse... :)

brownbook · Jun 23, 2010

UGH, UGH!!!! I've been nursing 27 years and I still hate charting. I still hate writing the same bland blah things over and over. Patient alert and oriented times 4, no complaints of pain, vital signs stable. Or, Patient drowsy, easily aroused to verbal stimulation, maintains own airway, returns to sleep. Or, complains of pain 5/10 medicated with fentanyl 50 mcg, tolerates well, (5 minutes later) patient states pain 2/10 "I feel much better." It does seem so repetitive and "rote" but learn a few simple key phrases. Put anything that can be measured in centimeters (keep a small ruler with you). Use patient quotes. What I wrote above is in addition to a graphic charting of vital signs and check boxes. Learn a few key "nursey" sounding phrases. Don't write a book. There is a fine line between not charting something versus writing so much that the defendants lawyer (and believe me that is what the bottom line is), will use to question you even more with.

luckyRN112 · Jun 23, 2010

If you still have your health assessment book from nursing school, try looking at some of those examples. Or you can search online for more. The more you read correct charting examples, the better you will be.

KnittingRN7 · Jun 23, 2010

I am sad to hear your facility is still using narrative notes, most with electronic records have gone to flow sheets for assessments, education and care plans. We write a narrative if there is a major change or Dr call. Most notes have some format template and we fill in the blanks making it faster. I have always used regular language instead of making sure I always use the medical term. Maybe your facility needs to check around and find a better system. Charting long open ended notes so many times a shift is way too time consuming for you and not an efficient use of your time.

KBRN413 · Jun 23, 2010

I'm extremely greatful that my facility has online documentation. The only note we have to write is based on our care plan, and even that is online. Our shift assessment is classified as our nursing outcome summary. Definetly a lot easier! With this new law, I think all facilities have to go paperless before 2012. Am I wrong???? :yeah:

TDCHIM · Jun 23, 2010

I'm extremely greatful that my facility has online documentation. The only note we have to write is based on our care plan, and even that is online. Our shift assessment is classified as our nursing outcome summary. Definetly a lot easier! With this new law, I think all facilities have to go paperless before 2012. Am I wrong????

Perhaps you're thinking of the general "meaningful use" EHR system requirement from the HITECH act? That one penalizes facilities and physicians who don't meet the standard by 2015 (the penalty is 1% of Medicare receipts the first year, increasing by an additional 1% per each year not in compliance - current maximum penalty is 3% by 2017; there could be additional higher penalties in later years).

2012 (well, 2011-2012) is the year when incentive payments to early meaningful use EHR adopters start being paid out, so maybe that's what you're remembering.

The following link provides a fairly concise explanation of how the whole deal will work: http://info.valantmed.com/blog/bid/33390/Stimulus-Incentive-FAQs-EHR-EMR-certification-meaningful-use-eligible-providers

Redhead28 · Jun 24, 2010

Remember your charting is telling the story of your day with that patient. You tell all the facts, and anything said to you. In the case of Pediatrics a suit can be brought by the patient until they turn 21, sometimes that would be 21 years later. All you have is your charting to try and remember what happened that day.