Charting...

Charting smarter: Using new mechanisms to organize your paperwork

http://findarticles.com/p/articles/mi_qa3689/is_199509/ai_n8726579/pg_1

I was basically taught not to over chart, because if you ever go to court it will be easier for them to read in to things that did or didn't really happen. I chart to the abnormal; anything out of the ordinary for that patient is worthy of a note, otherwise there's not really anything to say. The exception to that is if nothing out of the ordinary happens, then I chart something generic about the patient having no change this shift, vitals stable, will monitor or something to that effect. That is just what my preceptor taught me and I'm sure everyone is a bit different, as one of the nurses I work with charts every little thing it seems, when many of these things are repetitive (no need to say assessment complete in a nurse's note when they can just flip the page and see that your assessment was in fact done).

i too was taught not to overchart or double chart. most of our flowsheet is charting by exception ( check boxes) i check whats applicable to my patient and only write a note on whats not coverd in the check boxes.

your notes look similar to what i'd write

My facility uses the PIEP..I HATE IT!! P-procedure or problem I-intervention E-evaluation P-Plan here's my typical PIEP

P-s/p PCI with 2 DES LAD R groin MYNX

I-recied pt. from cath lab AAOx3. Pt. is s/p PCI with 2 DES LAD R goin MYNX closure device. Checked groin no bleeding no hematoma. Pt is on NaHCO3 @80cc/hr x's 9 hours started at 5pm and to be d/c'd at 2am. Integerllin Gtt @ 12cc/hr x's 18 hours started at 5pm to be d/c at 11am. BP q15 min for 2 hours, then q30m for 1 hour then q1hour. q15 min groin checks for the first 2 hours.Told pt. to report and CP,SOB wet or warm sensation from the groin site, N&V, or any pain or discomfort. Instructed pt to keep R leg flat and straight for 6 hours. HOB

call bell with in reach.

then I document the various times interventions were done through out the night..and any problems the pt. had and who I contacted and what the outcome was. If the pt's is AC/HS FS I document the BS eventhough we have a medex for that.

E- VS stable, SR on the monitor, Integerllin infusing, no bleeding no hematoma, HL#22 LAC, no c/o of pain or discomfort, AM labs done, AM EKG done, due meds given, any plan for the pt(discharge, rehab ect..) call bell with in reach

P-con't to monitor pt. Endorsement given to XZY Nurse

Then I sign my name

But that's with a cardiac cath pt. I get all kinds of tele pt's and have learned what to document but using the PIEP..which is we call the Pipe..at first my document was horrible but you get a hang of it!!

Good luck