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Discussion

Charting

For your nursing note, what do you generally do? I have seen 'status' (in diap format) notes that include all pertinent info (pain, out of range labs, ect) with the interventions on them, and then others will do a focus note (like on pain) (like in nursing school) but nothing on the rest of status of the patient . For me, it would be hard to do multiple focus notes, so I generally do a status type note.

Also, do MDs generally read these notes on their pts?

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We chart assessment and nursing dx in computer. I put an admission note, d/c note, telemetry strips and anything out of the ordinary in the chart. Some docs will check out what is written in the chart, but I don't think they ever look at our computer entries.

I hated charting in nursing school. We did SOAP notes mostly and I never felt like it was of benefit.

Different hospitals have different set-ups.

We use charting by exception by computer. So when we chart our assessment, that is it unless something out of the ordinary occurs. We also have little prompts for abnormal labs/critical labs where we can document when we notified the MD.

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