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Discussion

Contemporaneous Charting

Hi,

I have a question about how many of you do contemporaneous charting, they seem to be trying to implement it here, but I'm not quite sure how to actually do it. Does anyone have any experience with this? Instead of writing my notes at the end of the shift, and it would be in one entry, I would be writing multiple entries? How practical would it be/is it really?

I'm still learning what should go into nursing notes aswell, but the way I have been doing it so far is just notating things outside the normal limits, or dressing changes, medication administred as charted, IV fluids, IVAB's, mobility.

Here is an example of what I normally write at the end of the shift:

Nursing 1430hrs Pt showered with assistance this am, wound dressing changed no obvious exudate, pink, observations attended and within normal limits, IVAB's and medications given as charted, Pt stated pain was 7/10 analgesia given as charted with effect nil other complaints voiced, IDC insitu and draining well ----------------

--------------------------------------------------------------------------Michelle123 (AIN)

This is pretty much along the lines of what other RN's do on the wards that I work on, but I don't want to do something just because everyone else does, I want to do it because it is the best thing for the patient.

Featured Replies

  • Expert

please see this recent thread on narrative documentation. you can combine everything that happens during your shift into one nursing note if that's what your facility is requiring. you are correct in your approach that you should be noting things outside the normal limits, dressing changes, medication administered as charted, iv fluids, ivab's, and mobility. i would also include any effects of the medication and ivs given as well as how the patient is responding to the various treatments and nursing interventions you are carrying out, particularly the ones that have been ordered by the doctor. this is how others know if the plan of care is working.

If I understand correctly, your facility wants you to chart as you go, so if someone needs to reference a patient's chart during your shift, it will always be close to current. That is what contemporaneous charting is.

~Mel'

That's how I chart---as I go. I can't rely on my memory at the end of a 12+hr shift. Too many things are going on. I also chart every encounter I have with physcian. It's simple and easy. Our charting in on the bottom of a huge flowsheet, and that way it co-incides with the vital signs, I/Os and med gtt dosages.

  • Author

Where I work we have the bedside chart , which has the spot for medication charts, fluid balance charts, IV fluid orders, and places to record observations, limb obs, pcaobs etc. The only spot for notes is at the chart at the nurses station (on the ward I work at there are little mini stations for 4-6 beds which is helpful) this includes all the history, tests, etc and here is where everyone who has anything to do with the pt will write, PT, Dr, Pharmacy, social workers etc.

Generally I do my first round where I introduce myself the the pt's, and see if there is anything they need first off, then I will start morning obs (at this stage as an AIN I don't administer meds, just basic care) then if there is an issue with those will inform the RN, if I was charting as I go, then this would be when I would make an entry?

Nursing 0800hrs Observations attended temp 37.9, pt states pain 7/10 RN Smith advised, Pulse, Resp SaO2 and BP within normal limits ---------Michelle123 (AIN)

Ok, I think that I am starting to get it now, and then I can keep making notes like that.

Nursing 0900hrs Analgesic administered by RN smith as charted with effect, pt states pain 4/10 and temp 36.7 --------------------------------------Michelle123 (AIN)

Nursing 0930hrs Pt showered independently once set up ----------Michelle123 (AIN)

So I am thinking that would be more like what they are asking.

Thanks for your help.

the pace that I am working at now does not have narrative charting for this unit EXCEPT if the patient is a admission or discharge....I think it is a bit strange... There are places to note if problems arrize, but there are no shift notes as such - anybody else run into this???

I chart by exception. If it's normal it's on the flowsheet and if it's abnormal (i.e. you have something you weren't born with in you or flowing into you) it's on the flowsheet and I write it in my narrative.

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