Clinical questions

Mike A. Fungin RN · Aug 9, 2009

If there are any websites like that, they aren't likely to be very useful.

Basic knowledge about charting, i.e. terminology, abbreviations, legal considerations, you'll learn in school.

Beyond that, know this, every facility charts differently. Some use paper, some use computers, and there are about a million different versions of both paper and computer charting.

Part of each clinical orientation will be learning what you need to know to chart at a given hospital, then you get to reinvent the wheel when you move to the new one.

It's not as bad as it sounds. Rest easy, you'll be given the info you need on this when you need it.

Good luck.

Meriwhen, ASN, BSN, MSN, RN · Aug 9, 2009

Look at the chapter on charting/documentation in your fundamentals textbook for the main guidelines: patient's subjective data should be transcribed verbatim as much as possible; your objective data should be detailed; you should be non-judgmental; avoid using terms such as "good" and "bad" and instead actually describe what you see in the patient; and so on.

I won't list them all: seriously, go and read the charting chapter before your first day of clinical because (for the most part) the key points of documentation are not going to change no matter what facility you go to or what charting system you use.

But it is like Mike said: you're going to have to "relearn" how to specifically chart at each clinical site since everyone charts differently, but as you progress further in school you'll get more comfortable with charting and switching styles will be easier.

melmarie23, MSN, RN · Aug 9, 2009

charting varies from hospital to hospital. No 3 hospitals that I have been in thus far charted the same. Two had computers on wheels and had their own charting system, but both were very different from each other. The 3rd hospital paper charted. So it really varies.

You will learn it as you go. Don't worry.