Charting

Tweety, I've looked at that one and was not impressed. It really covered the types of charting, no what to chart.

I keep seeing an ad for a book called Chart Smart, put out by Lippencott. I looked for it at my local B&N, but they didn't have it in stock. I like to really LOOK before I buy, nursing books are expensive. If you take the leap on this one let us know how it is:)

Anyone have any good sources for a "how to chart" book for an oldtimer? My charting could use a little dusting up. I see they make a "Charting Made Incredibly Easy". I'd like a reference that I can refer to at work and keep in my locker perhaps. Thanks to anyone that can help.

The best way to findout how you need to chart is to talk to a legal nurse, medical malpractice lawyer, or a nurse who has been to court.

The best way to findout how you need to chart is to talk to a legal nurse, medical malpractice lawyer, or a nurse who has been to court.

I've been to three depositions and it it's nerve wracking to see my notes copied in the position of a lawyer for sure.

Tweety, I've looked at that one and was not impressed. It really covered the types of charting, no what to chart.

I keep seeing an ad for a book called Chart Smart, put out by Lippencott. I looked for it at my local B&N, but they didn't have it in stock. I like to really LOOK before I buy, nursing books are expensive. If you take the leap on this one let us know how it is:)

Thanks for your opinion.

I think that Chart Smart might be similar to one I'm looking for. I would like one that has examples, for instance what to chart for a dressing change, a patient altercation, etc.

Anyone have any good sources for a "how to chart" book for an oldtimer? My charting could use a little dusting up. I see they make a "Charting Made Incredibly Easy". I'd like a reference that I can refer to at work and keep in my locker perhaps. Thanks to anyone that can help.

incredibly easy series on charting is pretty good.

may I know how much is the chart smart book?

may I know how much is the chart smart book?

ISBN: 1-58255-987-2

List price is $42, B&N price $34 and if you have the B&N membership $31 and free shipping.

If you buy from Lippincott it's $39.95 plus shipping.

According to the ad in nursing magazine it does have examples. It says..and I quote...Know precisely what to document--essential documentation, skip the guesswork with handwritten examples to guide you.

We are going to computer charting next week, so I'm sot sure how much this would help with that type of charting. There really is no place to do narrative notes on the system we will be using.

I recommend "Nursing Documentation: a nursing process approach" by Patricia Iyer. She covers the legal angles thoroughly, with examples of what to include and mistakes to avoid. More information at http://www.medleague.com/webstore/med_league/nursing_documentation.htm

No, it's not cheap. But it's very thorough.

I'm glad you brought this subject up Tweety....I'm paranoid about not charting enough. I looked at the webpage SweetOldWorld posted for the book by Patricia Iyer. It looks great! I went to Amazon to see if it was any cheaper than $79.95 and that edition is not any cheaper. But I did find the previous edition for $4.97. It looks like it has most of what the 4th edition has.

Okay how about throwing aorund some charting tips here. Here's some sites I found info on -

http://medi-smart.com/documentation.htm

http://www.malenursemagazine.com/charting.html

http://www.nso.com/newsletters/features/common.php

- Failing to record pertinent health or drug information - Suppose the patient has an allergy or a disease (such as diabetes, hemophilia, or glaucoma) that his caregivers need to know about. But you forget to record that on his chart. You could end up in court, as did a nurse at a large metropolitan hospital.

- Don't leave blank spaces, lines, or boxes on charts. If you don't use the space, draw a line through it or write N/A (not applicable).

Here's an interesting one-

The nurse noted in the patient's chart that she had removed the catheter, but did not record the time of day. Later that day, the patient was unable to void her urine. According to the court record, because the nurse who removed the catheter did not record the time of day, there was a delay in reinserting another catheter to enable the patient to void. The Court of Appeals of Georgia faulted the nurse who removed the catheter. The court ruled it was negligent nursing practice for the nurse not to have made note of the time of day when the catheter was removed.

i use narrative style the shorter the better.

Here's an interesting one-

The nurse noted in the patient’s chart that she had removed the catheter, but did not record the time of day. Later that day, the patient was unable to void her urine. According to the court record, because the nurse who removed the catheter did not record the time of day, there was a delay in reinserting another catheter to enable the patient to void. The Court of Appeals of Georgia faulted the nurse who removed the catheter. The court ruled it was negligent nursing practice for the nurse not to have made note of the time of day when the catheter was removed.

actually, charting the time of removal is pertinent since one needs to know when pt is dtv.