Documentation

[mycatmax]

I just started my new RN job about 2 weeks ago. I feel like things are going pretty good except that I don't care too much for my documentation. I'm actually pretty embarassed to even write this thread!

I always felt uncomfortable charting things in school with my instructor first going over my notes.

I just bought the book "Charting made incredibly easy" to kinda help me out.

My two questions I feel very stupid for asking......

I always see "per" written in the notes. Like "per" doctor's order, or "per" patient. What exactly does "per" mean? I want to make sure i use it correctly and in the correct spot in the sentence.

"noted"; "bilateral pedal edema noted".... ??? "noted" goes at the END of what you observed? So if I was assessing a patient with lung ca or something and they were sob, and had audible wheezes, I would chart something like "Pt noticeably SOB at rest. Audible expiratory wheezes noted. Lungs decreased bilaterally c wheezes throughout."

I just feel like my documentation is atrocious. I don't really feel that i have any trouble knowing what to assess, it's just that i feel like i do not know how to word my assessment findings.

Also, how do you chart common findings? by that i mean how do you word certain things that you find your self charting often.

Thanks for any input!

[TheCommuter, BSN, RN]

'Per' means 'according to' or 'in accordance with' or 'by'

For example, "Flushed PICC with heparin and NS per physician order" really means, "Flushed PICC with heparin and NS in accordance with the physician order." Additionally, "Last BM on 8/9/07 per pt" really means, "Last BM on 8/9/07 according to the patient." "Patient hydrates per self" translates into "Patient hydrates by self."

Moreover, there's another guidebook called Surefire Documentation that might prove helpful. Good luck!

[neneRN, BSN, RN]

When I first graduated, I found it really helpful to read other nurses' notes to see how they worded things or made their documentation "flow" well. Seeing many different examples helps you find your own style of charting.

[ICRN2008, BSN, RN]

I have found that the main difference between charting as a student and charting as an RN is the length of the note. As a student, I wrote everything in my notes, including normal findings. Now I chart about abnormal findings, unusual occurrences, and progress towards discharge. I also always chart VSS, afebrile, no c/o pain/nausea and parents at bedside if these things are in fact true.

I learned by spending time reading other nurses notes. In the end, I try to remember that my note is a legal document. It is the only way that you will be able to prove in court that that a patient refused a med (not that you just forgot to give it), that a parent asked a question about a specific issue and you did some teaching, etc. When in doubt, try to be concise but write as much as you feel you need to in order to protect your license.