Does anyone knows any good book on documentation?

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I totally suck at writing notes.I never know how to start a note and I always repeat some stuff that I arleady charted,my notes are way to long....Currently I'm reading a book called a complete guide to documentation? I need an improvement,does anyone knows any websites,books about a proper nursing documentation??!

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Specializes in Med Surg, Ortho.

I don't know any books on documentation. What do you find difficult

about it? Just state the facts, what did you do for your patient, interventions,

chart by exception.

Charting has become a lot easier for me. Just state what you see. I always

document and assess my pts IV site at shift end as well.

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Specializes in Infusion Nursing, Home Health Infusion.

Western Nursing CEUs has the best CEU course on documentation I have ever seen. I was very impressed with the course. Just google western CEUs and select nursing and the state you are in. It also gives you great tips on documenting to avoid litigation (A very important thing in this society)

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'Documentation made incredibly easy' seems like a good read. I looked it over at Barnes and Noble a couple of weeks ago.

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Specializes in Neuro/Med-Surg.

I have the SAME PROBLEM. . .and I was a technical writer before becoming a nurse! lol - I think I worry too much about being sued for leaving something out or using the wrong word or blah blah blah. . .

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The biggest problem I have with charting at this time is getting it done in the allotted time frame, as my client's family (home health) expect to see me hovering over the client at all times and always interrupt me when I am charting. I also like how they have to go into the "make the patient comfortable" ritual right when it is time for me to leave, in order to delay signing my time sheet until after my shift is over. I leave things out that I intended to chart because I am interrupted so much from my work routine. I expect that this is dangerous, legally speaking.

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I agree and "Charting Made Incredibly Easy" as well.

'Documentation made incredibly easy' seems like a good read. I looked it over at Barnes and Noble a couple of weeks ago.
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Specializes in COS-C, Risk Management.

Because you're in home health, documentation books geared towards hospital nurses are not going to be of the best use to you. Try these books for information on home health reimbursement and how to document in the most effective manner:

Marrelli Handbook

Home Care Nursing Practice

Home Health Nursing Assessment and Care Planning

Orientation to Home Care Nursing

Best advice ever (and it's free): document to the nursing interventions and goals as listed on the 485.

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