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Discussion

Charting

Evening everyone,

I am new to allnurses and I could benefit from some help. I have been a nurse for 12 years and have never hard any problems with my charting. Then I moved to Georgia and problems begins. As of last Thursday I was placed on probation and 14 of my patients was taken from me. From what I'm being told it's because my charting is poor. I have taken webinars to help me improve but for some reason I'm not getting it. Left me explain. I work for an insurance company and I do visits as a care manager. There is no nursing involved with this job. My job is to monitor and complete my care plans. Easy right? That's what I thought until the headaches began. So far as I mentioned before I was told that my charting was poor, then I'm told that I'm only right two sentences, the I'm told that I'm writing to much. What I would like to do is provide a sample and please pick it apart. I'll say that I'm seeing a 80 yr old diabetic who need diabetic shoes.

On arrive to clients home I found him alert and oriented. Client is able to make needs known at this time and denies pain and discomfort. Fasting blood sugars were reviewed and are within normal ranges. This morning blood sugar was 110. No s/s of hypo/hyperglycemia noted. During visit client and FCM discussed need for diabetic shoes. Client states that he can benefit from these shoes but is unsure on how to obtain them. FCM placed a call to John Smith to have client fitted for shoes. Mr. Smith states that he will give client a call within two-three business days to schedule a day that is good for both client and Mr. Smith for a home visit. Upon completion of visit a visit is scheduled for next Thursday August 14,2015 between the times 9am-10am.

Please if you see any problems this this note please let me know. I love my job and my client and I don't want to lose them.

Thank you

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    • Featured Replies

    • Admin

    Welcome to AN! Even though you've provided a sample, it would be really hard to provide feedback without knowing the policies for documentation at your workplace. Have you had the opportunity to review the policies? They can help guide you into improving your documentation to fit the expectations of the employer.

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    Great advice I can give is using short worded sentences and getting to the point with using as little unneeded words as possible. Also try and chart only the important things. When I started my job as a nurse I had issues with charting and they told me exactly what I told you and it has helped a lot. Don't over write and keep it simple. :-) hope I helped.

    Example: client a&o, denies pain and discomfort. Fasting blood suger within normal range. Etc

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    • Expert

    Your immediate supervisor should be cluing you in on what they want. They should have done that before you started the job. Now that they have determined that they don't like the way you are doing it, it is imperative that they work with you until you get just exactly what it is that they want. If they don't take the time and effort to do this with you, you can be assured that they do not care if you remain in this position at all, and they care even less about getting the documentation the way that they want it. We do not know what is on their mind, so we can't speak for them.

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    Caliotter3 is absolutely right you need to go to them and say hey, what is it that is wrong with my charting? You can't fix the problem if they don't point out exactly what is wrong.

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    Hi georgia! Glad u are here with us at AN!! I have benefitted SO much since joining the forum here, whether it be feedback, questions or just to vent.

    I agree with PP, if u talk to your supervisor and maybe ask specifics - that might help - if u need to, make some notes when something comes to mind. (If I'm talking to someone like that on the phone or in person I may not remember everything I wanted to ask about but it hits me hours later, - When washing dishes or in the shower, ect)

    That may help - be sure to ask specifics - if they didn't like the way something charted was worded, how can u phrase it better next time, key words that they may want or not want.

    Hope that helps a little!

    Anne, RNC

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    I have not been in home health and I'm not sure what your employer is looking for. A head to toe assessment? What is the reason you are visiting this patient?

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