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Discussion

Charting Question

After receiving report what is the first thing that you write on a patient's chart?

It seems that most nurses start their notes off with "Received the pt. in bed..."

I was told way back when in nursing school to never start with that phrase because you were not receiving the pt. from anywhere. You may start with "Received report from...." then report your observations. This was a major discussion in work today.

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  • Experts

Attempting to be very diplomatic, when working on in ICU or on a floor for that matter, I usually start with "First encounter with patient at.......",

this way it is documented that this is the first time that have had an encounter with that patient for the day, and the first time that this paitient is under your care. Especially important, if another nurse was caring for the patient from the beginning of the shift and then assignments got changed for whatever reason....................

By the way, WELCOME to Allnurses.com........ :balloons:

When i get a new admission, transfer i always start off with recieving the patient from ER, ICU, PACU, etc, then write observations about IVF, foley,LOC,any dressings, drains, skin condition, decubs or breakdown areas. Things like that. Dont know why you couldnt write that you recieved patient to the unit, if they werent on your unit they had to be someplace else first right? We dont necissarily get a formal report from ER, or fast track or another unit the patient has come from always. Documenting that "patient arrived from Dr. so&so's office as direct admit to room blah blah. Observations. Will call office for further orders". Then go back and document orders recieved from dr's office. Documenting patient recieved from ICU, or ER, or OP via stretcher or wheelchair, dont know what makes the difference.

I dont see the problem.

    •
    • Experts
    When i get a new admission, transfer i always start off with recieving the patient from ER, ICU, PACU, etc, then write observations about IVF, foley,LOC,any dressings, drains, skin condition, decubs or breakdown areas. Things like that. Dont know why you couldnt write that you recieved patient to the unit, if they werent on your unit they had to be someplace else first right? We dont necissarily get a formal report from ER, or fast track or another unit the patient has come from always. Documenting that "patient arrived from Dr. so&so's office as direct admit to room blah blah. Observations. Will call office for further orders". Then go back and document orders recieved from dr's office. Documenting patient recieved from ICU, or ER, or OP via stretcher or wheelchair, dont know what makes the difference.

    I dont see the problem.

    I think that she is referring to just getting report from another nurse on your unit. Lets say the patient has been there already two days. She is asking what you write...............sure when you receive a patient from another unit, you write "Received patient from--- via ---(bed or cart), etc..........

    :balloons:

    From the ER, I write "Arrived from ER via stretcher (or whatever)......".

    For patients who are already there "Initial assessment completed..............blah blah blah...." and write what I see and do.

    I think I do use the word "recieved" sometimes...."recieved from recovery room, or recieved from the ER". But usually if the patient is coming from somewhere else. For patients already there, if someone wants to know who I got report from, it's in the charting.

    I think it's semantics to say "recieved patient....blah blah blah.." when the patients already there. I don't think it's a big deal myself and don't see anything wrong with it. But I'm willing to learn.

    If I am just receiving report on a patient in the unit and assuming care, if I write anything, it is usually "1900: Assumed care for patient...denies pain (or whatever the case is)...see charted assessment." I feel that since I am signing my name at the bottom from 19-07, it is pretty obvious that I am assuming care for those times...if anything specific comes up in the initial assessment, then I cover it. I do work in critical care so I usually have pretty fequent assessments/VS to cover on my flowsheet.

    If the patient is on the unit I start with "assessment completed,...." that works best for me. If the patient is trasferred from ICU I state "received pt from ICU via bed/cart...". You could always say "assumed care from ....RN, report received at this time". Whatever works for you!

    • Guides

    Since I come on shift at 2:45 a.m. I write "Asleep with even and unlabored resp." or "Asleep with snoring resp." :chuckle

    I was taught never to use the word "patient" in the narrative as it is obvious you are talking about the patient.

    steph

    Since I come on shift at 2:45 a.m. I write "Asleep with even and unlabored resp." or "Asleep with snoring resp." :chuckle

    I was taught never to use the word "patient" in the narrative as it is obvious you are talking about the patient.

    steph

    I graduate nursing school next month. Our instructor tells us that after report go and make your walking rounds to check on pt, evaluate IV fluids, is bed down?, etc. Then to chart in the nursing notes "Walking rounds, bed down, side rails up x2, call bell within reach. Pt resting quietly [or whatever is going on]" She gave us a good reason to do this first thing after report. Apparently if you were to go to court and there was nothing written in the nursing notes until...let's say 3 hours into your shift...a lawyer could sway jury to actually believe that the 3 hours into your shift is when you 1st laid eyes on the pt.

    Apparently if you were to go to court and there was nothing written in the nursing notes until...let's say 3 hours into your shift...a lawyer could sway jury to actually believe that the 3 hours into your shift is when you 1st laid eyes on the pt.
    If you didn't write it down, it didn't happen! They're already drilling that into our heads at my school, and I'm only in the Critical Thinking pre-req for nursing. I don't even start the actual nursing program until August. But it is a good thing to learn & consistently do. If you get in the habit early, you will always do it automatically. (Like I still write military dates due to a job 3 years ago that used that dating system. Ex. - 12APR04 is today's date.)

    Amelia

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