Charting

Well when I was working in med-surg..

I find that at the end of the day it is just too much to try and reflect back on many pts. so my assignment was very specific.It was divided in groups.

i/o, vitals, prn's, lab, new orders... etc... during pt's meals I'd be able to find some time to sit down and chart these things down... I don't know if you are talking about bedside charts in which I chart at the same time as I found the findings... Docs do rounds so it is very helpfull that they have up to the minute data about that pt.. As per the main charts I did this on meal times, or whenever I found another time... Some facilities chart by exception and they do not want double charting ... therefore you need to find out the method of charting being used...

ex. if you charted in the Meds prn section you gave dose and time.. you can state the effect in the bedside chart.. if they had Pain flow sheet..

NOw you are not required to rechart all that in the main chart.. I used to say prn analgesic given X4 this shift with fair effect.. pain scale 6-7 prior to treatment with follow up found to be 3. etc... Again I strongly urge that you find out the charting method.. here we got: soap, dar, by exception..

Good luck it does get easier as you sink in the routine...

:redbeathe Hello,

I am a cardiac office nurse and need a quick flow sheet for initial charting. I would like to include stuff like VS current meds etc. but made so that every visit I could compare the info to the prior visit. Any examples?

Thanks:heartbeat