Charting/Nurses Notes

[StormyCD]

Hello everyone, You all helped me so much with my Frequent Faller questions, So I have another question.

I have to give an inservice on Charting. I work in a nurseing home and the charting can, at times, be very minimal and often confusing. Does any one have some hints for the inservice? Or does anyone know where I might find information on the internet?? I'd like to teach my co-workers to chart more detailed information, knowing that this may save lots of problems in the future...thanks in advance...

StormyCD

[BBFRN, BSN, PhD]

Have you thought about offering flowsheets that they can check off on?

[Bambi]

Hi,

teach them to chart with DAR or Soap notes.

Dar: Data (objective/subjective), Action & Response.

SOAP: Subjective (data), Objective (data), assessment & plan.

Hope this helps.

[flowerchild]

Assuming that you already have paperwork in place and are currently using the forms and notes...........Refer to your P and P and teach them the things they need to know from the P and P. You can not just change the forms or type of charting you do without first changing the policy. Changes in charting would warrent a commitee and many hours of nurses time which I doubt you will get. So stick to what you already have. Unless there is a serious flaw to your forms then there is no reason to change anything. You just need to teach them to the proper methods of charting that your facility has set the guidelines. You will be doing yourself and your coworkers a great favor by teaching them from the P and P, b/c if they are not following the P and P they are hanging themselves out on a limb everytime they do not chart as specified and believe me the facility will never back anyone who hasn't followed their guidelines. Good Luck and have fun with your inservice.