Does anyone know of a good documentation guideline?

I wondering if anybody has any ideas of a good chart note books out there. Because i know i need to improve in my charting cause charting is everything in nursing.

For LTC no, the closess is Chart Smart or Mosbys Surefire Documentation but they cover mostly acute care issues, but most facilties have there own guidelines.

Some suggestions

always include vitals, whom you reported to and what they ordered if anything, only put what you see no guessing no medical diagnosis just what you see or do or quote the patient if possible if there is any s/sx of distress, c/o pain or discomfort and any safety measures in place, never state the you will continue to monitor unless you are there for 24 hours straight never quote whay some else says.

when to chart

medicare charting

during the full course of antibiotic or any IV meds make sure you have a tempeture

and infusions site assessment

first 7 days of a new medication or new dose of current especially pysche meds

pysche/behavior notes

I&As

a rule of thumb if its on the 24 hour report chart on it!