Critical Thinking question for practicing nurses

[Bjm1982]

Hi,

I'm in my first semester as a nursing a student and we have a writing assignment due tomorrow. The question is this:

Interview three practicing nurses and ask them to describe the documentation methods they have used in their practice. Which methods did they prefer? Which method was more effective, time efficient, and easiest to use?

I appreciate your guys' time and help with this.

Thanks in advance!

[Daytonite, BSN, RN]

it was almost exclusively narrative charting. it was only in one or two places that charting by exception was used where we just checked off normal and abnormal assessment items. i would still end up writing narrative notes to explain things in more detail. charting by exception is obviously more time efficient and easy to use, however, i believe that narrative charting is more effective and it saved my butt on more than one occasion. one of the problems with it is that you need to remember the items that you have to chart on.

[Bjm1982]

Daytonite, thank you very much. That's exactly what I was looking for. Any others want to chime in?

[al7139, ASN, RN]

I have used narrative, and exception. As daytonite said, exception is way faster, but you do have to be careful to be detailed in your abnormal charting. I found that it's easier to write things down on a "Brain" sheet to refer to when I do chart.

WE have just recently gone to an all computer charting system, where we can just point and click on a flowsheet for assessments. The one drawback is there is not alot of space to be detailed in your findings if they do not quite match your options for abnormals. For this you have progress notes (like nursing notes) where you can be very detailed in your documentation. If I have to do this, it can take a little longer.

Hope this helps.

Amy

[locolorenzo22, BSN, RN]

We use computer charting in our workplace, where narrative charting is important for the admission assessment, and often the systems are broken down for all charting. However, I personally do not use the WDL section very often, I find it easier and more butt saving to do complete charting on every patient. If I can't seem to find a area where something fits, or if I have to chart exactly what happened if a patient started going south, the narrative section has saved my butt more than once....lesson learned the hard way here...when I got in trouble over a stupid patient who started making things up about me...

such is life...always chart more, not less, when in doubt....