I have just graduated LPN school and I am waiting to take my NCLEX. From all my studying I have done this past year I know how important documentation is and with that being said I have worked in clinical with many nurses and know not everything is by the book. At the same time though working in the hospital vs working in a long term care facility I've seen that documentation is completely different (from what I have experienced). My school did a preceptorship for the last 2 months of our program where we had to log in 200 hours with the nurse we were assigned. Learning this facilities online charting system was easy but it always puzzled me as to why you only really chart the medications and if there are adverse effects or pt refusals, basically only things going wrong or if the physician was spoken to (Yes there is extra charting at the end of the night where certain pt have have behavior, ABT, Med A/B, skin checks or whatever is ordered to be charted) and this isn't the only LTC facility where I have noticed this. Where as in the hospital the nurses I saw charting would document the position the patient was in upon entering room and that the call light was in place and there was no signs of distress, etc (Just like we are taught in school). I guess my #1 question is since I haven't had to much experience and i will be getting my first job soon, Does this sound right? Should I only chart what is asked of me to chart? or should I always take those steps when doing a med pass and hourly rounds and state my pt is in high fowlers position, tv on, pleasant disposition , no signs of distress etc. if this is genuinely the case? Also where would I add these little charting notes because for example on this system I worked on for 200 hr, the only place you could type your own comments was "progress notes", would it be acceptable to put hourly rounds charting there? (because like I said none of the nurses I worked with did)
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I have just graduated LPN school and I am waiting to take my NCLEX. From all my studying I have done this past year I know how important documentation is and with that being said I have worked in clinical with many nurses and know not everything is by the book. At the same time though working in the hospital vs working in a long term care facility I've seen that documentation is completely different (from what I have experienced). My school did a preceptorship for the last 2 months of our program where we had to log in 200 hours with the nurse we were assigned. Learning this facilities online charting system was easy but it always puzzled me as to why you only really chart the medications and if there are adverse effects or pt refusals, basically only things going wrong or if the physician was spoken to (Yes there is extra charting at the end of the night where certain pt have have behavior, ABT, Med A/B, skin checks or whatever is ordered to be charted) and this isn't the only LTC facility where I have noticed this. Where as in the hospital the nurses I saw charting would document the position the patient was in upon entering room and that the call light was in place and there was no signs of distress, etc (Just like we are taught in school). I guess my #1 question is since I haven't had to much experience and i will be getting my first job soon, Does this sound right? Should I only chart what is asked of me to chart? or should I always take those steps when doing a med pass and hourly rounds and state my pt is in high fowlers position, tv on, pleasant disposition , no signs of distress etc. if this is genuinely the case? Also where would I add these little charting notes because for example on this system I worked on for 200 hr, the only place you could type your own comments was "progress notes", would it be acceptable to put hourly rounds charting there? (because like I said none of the nurses I worked with did)