Documentation Resources

Nurses General Nursing

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I'm a new nurse on an extremely busy Progressive Care Unit. I am seriously struggling with time management and documentation. I thought my documentation was great until my manager said that there are holes in my charting. I'm having difficulty knowing exactly what to chart and how to verbalize it. I'm a communicator by nature and don't typically have issues with communicating so this is really blowing my self-esteem out of the water. I need some tips and need them bad!! LOL!! Please help!!

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Specializes in Ob/Gyn, Ped & PACU.

There are some really good threads in the student nursing section. Try looking in there for "charting". I just read some great examples yesterday so I know there are recent ones available. Good luck & keep your chin up, it gets easier with time.

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Specializes in Hospital Education Coordinator.

I would also ask for examples from the manager.

Basically, you want someone not familiar with the patient to be able to locate what they need and get a picture of what is going on. Good luck

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