Charting

If you are handwriting your physical assessments of your patients rather than using a check off sheet, it is generally easier to address things going from head to toe. Start with the head, address neuro problems (brain). As you move downward you have ENT. Think about the physical structures in the neck, the chest, abdomen, pelvis, bones (I only remember about bones and muscles when I get to the legs), and the feet. I try to visualize the patient's body as I'm writing these things. If you have a check off sheet, then your narrative should address the things that are NOT normal in the patient. Always make mention of the appearance of all wounds, and the status of IV sites, and any of a dozen different kinds of drainage tubes the patient might have. It is also, generally, a good idea to go through the list of doctors orders to address whether or not you've carried out any of them, such as a dressing change, ambulated the patient in the hallway, kept their lower legs elevated while they were in bed, kept the head of the bed elevated at a 30 degree angle, etc. Also, look at the primary reason the patient was admitted and make sure that you chart any nursing actions you took in relation to that.

I recommend that you make a guideline on a piece of paper for yourself to carry with you when you are in clinicals. That way, when you sit down to chart your narrative notes you will have a general guideline in front of you to help you remember what you need to address. Definitely include things to cue you into what to address with the head to toe assessment. As you realize certain things need to be addressed in your charting you can add them to this list. The list becomes a work in progress. I have one that I started about 27 years ago and I occassionally add things to it. Keep a copy of it in a file on your computer in case you lose your hardcopy one. If it is good enough other students will start wanting a copy of it from you. Start by writing things on it that your instructor has already critiqued you about for omitting them so you won't make those errors again.

Very early in my career I made out a sheet like this for patients with chest pain (I worked on a cardic unit). I was kicking myself for always forgetting to address one or two things when charting on it. The sheet included the questions to ask the patient who was having chest pain (location, description, oneset, any shortness, cyanosis). It included a list of things to remember to do (note the time, take the B/P, listen to heart sounds) as well as the hospital protocol for chest pain so I could follow it exactly. I would pull up a chair and sit with the patient and ask these things as I gave the first tablet of nitroglycerin, check the B/P, watched the time and then administered a second nitro table if needed. From then on my charting of chest pain was textbook, not to mention that the patients got the best care if I do say so myself. Moral: you can't depend on your brain to remember everything.