Discharge charting.....? I need help please

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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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This is your narrative nursing charting:

Neuro level

VS

findings related to admission (for instance if you had an asthma pt you'd write oxygen sats, RR, WOB? SOB? Adventitios sounds? Cough or chest pain? Even if those findings are negative, you still must write that there was no sign of those).

Education about condition, prescriptions, and follow up care

Give number of the unit/ward/ help line for them to contact if they have questions

How did the pt leave? What kind of clothing were they wearing? what kind of affect did they have at time of D'c? Did they walk/wheelchair? Did someone pick them up? Who?

It is your responsibility to have the pt safely leave the site of d/c

Hope this helps

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Specializes in Critical Care, Education.

Look up the organization's policy & procedure - charting systems differ, especially if you're dealing with EMRs. For instance, any 'disease/medication management' teaching should be limited to materials that are approved by the organization & these must be referenced in the documentation.

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