Criticize my charting!

RNontheroad · Mar 19, 2008

Not bad.

Here are a few things you might want to consider. Start from head to toe. It seems to flow more smoothly if you start with neuro and work your way down. It also helps to organize it in your mind and you are less likely to forget things.

Neuro-address weakness and ability to move. Grasps equal, generalized weakness...things like that. Is the gait steady? Speech clear, garbled or slurred? Alot of hospitals use the Glascow Coma Scale to assess neuro status. If you havent learned this yet, I am sure you will soon. FYI-confused people rarely know they are confused so the statement "denies confusion" is a bit akward.

CV-This is were I usually address temperature. Is the patient febrile? If the patient is on telemetry, what is the rhythm? Are pulses palpable in all extremities?

Resp-The only thing I would add is if the patient able to speak in full sentences or just a few words at a time? It is usually a good indicator of the severity of the resp distress. Also, you may want to note if any treatments were given and the patient response.

GU-looks good, just make sure you indicate if there is a foley or if the patient is continent or incontinent.

GI- What is the patient diet and how is their appetite? Again, continent or incontinent and what did the stool look like if you saw it. (yep, we assess the poop too!)

Integ-you need to be more specific on the wound. Is there drainage or odor? What treatments are being done to that heel wound? There are lots of fancy terms to discribe wounds and the surrounding tissue. I am sure you will learn them at some point.

You will also need to address any IV access or invasive lines that you have. They need assessed every 4 hrs as well.

Hope this helps. You are definately on the right track! It will get easier the more often you do it, and you will develop a "flow" that works for you. Good luck!

workingforskies · Mar 19, 2008

A good note. My mother is a PhD RN. When I was in nursing school, she told me that when you write an assessment, assume it is for a jury. What you write on a chart is the picture of that patient as you saw them at that moment. I have never forgotten that, especially with some of the less than stellar charting I see now.

My advice to you, learn to abbreviate as much as possible. That will save you a whole lot of time and pen ink/key strokes.

Since you are new, I will share with you a typical note I write about 90% of the time in an ER setting.

“Mr. Smith AAOX3. No c/o pain. PERRLA. Speaks clearly, answers questions appropriately, obeys commands, MAE. Ambulated with steady, even gait from WR to bed 8. BBS CTA. Resp. even, unlabored. Skin W/D/P. Abd. S/NT/ND (with) + BS. Cap refill

Clearly, this is a person with no problems. The reason he came in would be addressed in the note in more detail.

I can’t say this is perfect, but I have never gotten a complaint from anyone higher up about it and it has worked just fine for me thus far.

2 things off the top of my head to watch out for. When assessing pupilary response on a baby, write PERRL. NOT PERRLA. You will have a hard time explaining exactly how you got a baby to focus their eyes in order to assess for accommodation.

When assessing CMS distal to an injury, say, the base of a finger, don’t chart about pulses distal to the injury. (Unless you pulled out a Doppler.)

Those are 2 common charting mistakes I see all the time.

My 2 cents.

sweetsmiles2007 · Mar 19, 2008

you might also want to chart what you did about the various problems pt is having----

--85% on 5L, encouraged coughing/deep breathing, RT and MD aware or whatever you did about it.

--alert, oriented x2, RN reoriented to date, pt pleasant and conversing appropriately (most everyone will deny being confused--you want to give a substantial reason that the pt is not confused despite their only being oriented x2)

looks great!

Daytonite, BSN, RN · Mar 19, 2008

wound needs better description. no mention of drainage, size should be given in distinct measurements (millimeters, centimeters) and any dressings noted and described.

where was the cap refill evaluated in the upper extremities? nail beds? fingertips? how many seconds did cap refill take?

what is "fatigue+++ upon dangling at bedside"? i've never heard of a scale that rates fatigue like that.