Documentation and Charting

When I stepped out into the real world of nursing, I too was intimidated by documentation...but all facilities have different styles they want nurses to do.

One place was only chart by exception, so I only had to chart on issues that were in question or being of concern...none on other items unless they became a concern. The paperwork was actually a form and I could easily chart by check marks or filling in the blanks. Best paperwork I found, and got me thinking of issues clearer during my first job!

Then I worked in other places that were more SOAP (subjetive/objective/assessment/plan) in charting. Since I had learned such a systematic way to do my thinking from the previous charting forms...this was a breeze to me! I still find it a great way to do my charting!!!

Now, I work in assisted living where the charting is very laxed as far as form. I still do SOAP, and am one of their best charters! In fact, they hire me to do inspection of charting so we pass state audits as they occur! I also find SOAP to be excellent in really putting in your pts two cents by quoting something they say!

There are documentation links all over the internet. Some by companies that you pay and you get a certificate of completion for hours spent! Do a search :) (I am still a SOAP gal though...I like it!).