documentation

Documentation expectations and verbage usually vary from facility to facility. Some use paper, some EMR. Some have pre-made forms with check lists, others write on a blank note. For that reason, it's hard to suggest a written resource because it might not teach the same format as your facility.

Is there a way that you can review what other nurses on your unit have charted and get a feel for what their documentation is like? Otherwise, I would suggest sitting down with your manager and asking for some pointers.

Your charge nurse or educator should have some guidelines for what minimum documentation standards are in your facility. If you hit these guidelines, then that's a good start.

You might also ask if it would be possible to participate in chart audits of some sort; that would give you a chance to see how others are doing it. (Some might be good, some bad, but I can learn from both).

Every facility is different. Our notes are check boxes on the first page and a body diagram on the second page (for wounds, etc.) There is a place at the end of the second page to document anything unusual that was not addressed in the check boxes. Do you have a way to observe how the other nurses are documenting?

I read this post wrong or at least different from everyone else I think. I thought she was asking about verbage. Such as how to narrate parts of an assessment, not format.

I like to think I'm decent with words and charting...what exactly are you looking for? If you send me some assessment info or scenarios I could write it as a progress note as an example. I am not great with imagination lol.

Nothing like it. A "must have"....

hi handyrn, you are not wrong, i am looking for verbage. thank you.

hi ri,

verbage isn't a word, so that may be part of your problem:lol2:

i think maybe you could consider a head-to-toe approach in your assessment--

neuro

cardiovascular

pulmonary

abdominal/gi

renal/gu

peripheral/musculoskeletal

psychosocial

-- and then in each, write down what's important there, both positive and negative signs. for example, in neuro it might be, "awake, alert, oriented x5," which tells you that he's probably hitting on all cylinders; or "obtunded, responds to painful stimulus (sternal rub) by withdrawing arms and pointing toes, pupils equal and responsive to light," and whatever else applies to the patient's neuro problem.

now, if you can't think of what's important to assess and communicate in every one of these vital areas, what would be a normal finding and what would be abnormal and how to investigate that and communicate your findings, then we have a problem. could you clarify about what you need? give an example, perhaps?