Discharge charting..? HELP!

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Hi there,

I'm currently a student. I just have a question regarding proper charting when discharging a patient.

I know you would put something like this.....

"Pt d/c'ed with daughter. VS stable as per flowsheet.....[then i would put what teaching i did etc], prescription given"

Could you please share to me how you do your discharge charting?

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Specializes in NICU, PICU, PACU.

Ours is all electronic. But before that ours, for our peds floor, went something like; Bobby boy discharged home with mother at 2020. Discharge instructions on post op care, signs of infection and follow up appointments, prescriptions reviewed with mother. Personal articles given to Mother. Bobby boy discharged home per private auto. Keep it simple.

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Your instructors should be giving you tips and wording for charting on the patients they assign you. That is how it was back in the day. Have things changed that drastically? I know most nursing schools do not teach medical terminology. It's not a required course in some of the LPN and ADN schools I have been in touch with.

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