I've just finished up with my orientation & am now on my own, and I'm trying to find my own "style" regarding charting. We have a computer charting system that's pretty neat, you just have to click on all the right prompts in each body system, it walks you through almost every possible thing you'd want to chart on, or you can type in what you want if the selections on the screen don't really apply.
One new thing I learned the other day from a nurse, that I hadn't been told before, is in a trauma, ALWAYS chart a GCS on arrival and on departure. Oops, haven't done that before.
Another new nurse told me that in traumas, she always goes into all the neuro prompts and enters everything there (pupils, grips, facial symmetry, moves all extremities well, gait, speech, orientation, etc etc etc...there's a lot more that I can't think of right now). I've never really charted as much as she does on my traumas, just behavior & appearance (agitated, crying, whatever), orientation, and then the specific injury.
Does anyone else have anything specific that they ALWAYS chart on particular types of patients?
I've seen other nurses chart that they gave the patient something to eat, or that the patient appears to be sleeping...I've never charted those things. I have so much to do, I have never found the time to chart anything other than procedures (IVs, foleys, blood cultures), vitals, & meds. I know it's a great idea, gives a better picture of what happens with the pt. throughout their stay, but it's hard to find the time to chart it.
Another thing is charting that the MD was notified of a particularly high/low BP, heart rate, blood sugar, or whatever. I can see that's a CYA thing, & I should always chart that...but I often don't take the time to do it.
And finally, I see many nurses choosing the "no deficits noted" option on every single body system in our PC charting system. To me that's just cluttering up the chart, so when someone goes into read what the "real story" is about the patient (some docs read it before they go see the pt, some don't), it isn't giving any useful information. They will see an entire paragraph stating: cardiovascular: no deficits noted. respiratory: no deficits noted. musculoskeltal: no deficits noted....etc etc etc. Seems like a waste of time for the person charting and the person trying to read it.
So what about you all? Any tips on charting?
Last edit by vampireslayer on Oct 6, '05
Oct 6, '05
wow, broad subject. LOL
i guess i have a system but never really thought about it. it just developed on it's own.
i chart my initial impression of the scene when i go into a room. "pt sitting up in bed. safety rails up x 2. call light in reach. pt. laughing and talking with friends/family."
i then get a hx from the pt or family member.
then a focused assessment with any relating assessment factors. "crackles in bases bil. no lower ext edema noted." or whatever.
then i chart what i did about the assessment. "pt placed on O2. rt called for hhn."
that's the guts of my charting. but i also chart the little things. md to room, to ct per stretcher by rad tech on O2, po fluids given. tol w/o nausea/vomiting, etc.
make the time to chart even if it's "no deficits noted" because that says that you at least addressed the symptoms. a board of nursing isn't going to care if you feel it clutters up the chart. they will want the whole picture of care a pt received.
as far as trauma goes, GCS on arrival, any changes noted, and on discharge is my rule.
traumatic mechanism of injury always gets GCS, resp assessment, and belly assessment. "GCS ___, resp easy & even, no abrasions noted on chest, equal and even chest wall rise bil, BS clear bil per scope. Abd soft, nontender to palp, nondistended, BS x 4 per scope. urine sample sent to lab for eval."
keep your charting short, sweet and to the point but most of all CYA because it's your A on the line if/when that patient crashes. the procedural charting is important but the physical aspects of what you see is just as important. look at your patient.
Oct 7, '05
Here's some links about charting you may find useful:
At FindArticles there are 4 articles here on charting:
Do's and Don'ts of Nursing Documentation, also includes links to 10 other articles & books:
Narrative charting nursing:
There are also 2 threads at allnurses on charting:
Oct 7, '05
I think I overchart, but do not plan to do it. Sounds like you already have a really good basis to go on.
I've been taught to tell a story. When I look back at my charting, I think "If this goes to court, what can the lawyer nit-pick?" and try to work on that.
We also have computer charting- to me I love it b/c it saves time. Then again, I grew up with computers, so I can type a bit faster than the folks who are much older than me and grew up with paper charting!
We have promps under systems with each system, and we have the option to choose"n/a to complaint" or "WNL"- I don't think I have hardly ever used those. I still put resp even and unlabored and breath sounds clears, pulse regular in rate and rhythm, etc... I do a lot of typing in stuff also where there is not a prompt "denies headache, vision changes".
One thing I really overchart on is IV's. I used to put "IV site benign"- I've now started putting "IV site without redness, swelling or pain", put what fluid is infusing and how (gravity, pump, dial-a-flow) and rate.