Concise Charting

just the facts mam.....just the facts

Most of the charting nurses see is flowsheet type fill-in-the-blank type of charting. That is usually concise enough.

If something is important enough for you to need explanation, then go ahead and cover the subject.

Make good use of abbreviations that are allowed. If you read what the residents write in their daily notes, you will see the masters of concise at work.

I read a great article on charting...

cover all area of the nursing process...this will assure you cover all areas.

Keep in mind, charting is mostly for one reason and that is to cover yourself in the event you end up in court. It is VERY rare that a doctor will take the time to look at your notes. In my hospital they might ask you a few questions as they dash into the room. The next on coming shift might read a note, but if it's important, it's best to address it verbally at shift change to make sure it doesn't get missed. Any time you write something as a problem, always follow it with what actions you took to address the problem.

I always use the short stubby sentences:

EX: Patient at bedside. With two person assistance, transfered to chair. Patient able to stand with assist, required verbal assist with ambulation.Tolerated well with sats of 96% on room air for one hour.

Notice the pentameter: dah dah dah....dah dah dah.....nothing fancy just sporifice and clear...maybe not as clear as the next...anyway, my tip for the day. Hope you gain something from it!

Patient in duress example: Patient non responsive to verbal or pain ques.Skin moist color dusky. Breathing through mouth. Resp. rate of 10.Sating at 81%, Blood pressure 95/20. Venturi mask placed on pt. at 100% 02. Physician notified of condition. Received order to give Narcan stat.