Charting

As you guys know I am a new grad doing orientation on 1100-1200 del/year L&D.

I get the oppurtunity to put many outpatients to bed for NST's Labor checks, r/o SROM etc.... Our outpatient sheets have places to record vitals, labs, gravida/para, orders, meds, EFM's, chief complaint, edc, lmp, ga, ctx, membranes, movement and bleeding, then there is a large blank portion for notes. There may be other stuff but that's what I can think of right now.

I noticed several nurses tend to double chart. I think this isn't good and I don't want to do it but then I'm having a hard time with the subjective part.

This is something I might tend to put....

0930 pt presents from office for NST. EFMX2 to soft non-tender abdomen. Given H@O to drink. Will monitor. 1010 FHT 140's with accels to 160's. Pt discharged home with instructions -- verbalized understanding----------

Discharge instructions are on the back and there is a part for discharge time etc.....

Any suggestions?

[acuteobrn]

first tip...never leave a blank space, it makes it look like you didn't address it, if there is a place for notes, chart by exception if this is what your policy is. I peronally would fill in the spots provided and make a small objective admit note:

0930 pt. presents from PMD office for NST. EFM applied. FHT 140s. Abd soft non-tender. Pt. denies UCs. States 'baby moving alot'. Pt. verbalizes understanding and agrees to EFM.

0945 pt. given 8 oz. H2O.

1000 PMD notified of NST reactive. baseline 140-150. Ave. LTV. + accels x4 upto 160-165. No UCs recorded. Fetal movements x 12. no decels noted. VSS. Afebrile. DC orders recieved.

1005 Pt. d/c'd ambulatory w/ instructions and kick count sheet. f/u w/ PMD in 5 days.

some double charting, but need to make it clear and basically draw a picture of the strip... in case it is ever lost and this comes back.

this is just what i was taught.

others probably have better sugg. that i might learn from.