charting

Specialties Geriatric

Published

Hi guys i am a new nurse. i am having so much trouble with charting. I Need help with charting.. what do we chart when person FALL on your shift in long term care facility?? can someone please give me example? Also for s/p Antibiotic how do we chart for that? PLEASE THANKYOU

Specializes in Pediatric.

Hey! Hopefully you've gotten some help already.

One thing you could try to do (in terms of knowing WHO to chart for) is take your brain sheet, census, patient list... Whatever you use. Highlight in yellow the patients you plan on charting for so when you sit down to chart, it's wayyy less overwhelming.

A general rule, most facilities have a schedule or guide on q shift charting. Start with that.

Highlight anyone else such as...

-Patient on IV therapy

-Patient on abt

-Recent change of condition in the last 72 hours

-S/p fall

-PRN's (I don't chart every PRN in every narrative note, but I get most of them documented.)

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