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Favorite type of documentation style?

Posted
by guest1154907 guest1154907 (Member) Nurse

What’s your favorite way to document

Edited by Nurse1276

24 people have looked at this and no one is answering my question...

Loco-Bonita, BSN, RN

Specializes in CVIMCU/CVICU. Has 4 years experience.

Maybe you could elaborate on your question, as it is very vague and difficult to answer in its current formate.

Sour Lemon

Has 9 years experience.

5 hours ago, Nurse1276 said:

24 people have looked at this and no one is answering my question...

Response is not mandatory. There’s no need for a scolding. 😉
My hospital has a “required documentation” set of flow sheets, and I fill them in. I’m not sure I have a favorite way to do it.

meanmaryjean, DNP, RN

Specializes in NICU, ICU, PICU, Academia. Has 44 years experience.

OP: Your question is so vague. If 24 looked without answering, perhaps it's the question and not the audience. Throw us a bone.

14 hours ago, Nurse1276 said:

24 people have looked at this and no one is answering my question...

What is this?

Were the 24 beholden to you in some way?

DavidFR, BSN, MSN, RN

Specializes in Oncology, ID, Hepatology, Occy Health. Has 35 years experience.

As stated above your question is vague, but I think I know what you're getting at.

When I trained and first qualified in the UK (1980s) we had a "Kardex" which was just blank sheets. You free texted what you had done on a shift and noted significant events/outcomes.

Then they introduced care plans: a care plan with the patient's problems was written on admission (often not very well, often by a student nurse) and your documentation underneath had to be numbered, relating to the numbered problems. So if problem 1 was pain you would write : "1) complaining of pain in......."

Where I work now in France we have "transmissions ciblées" or targetted reporting, again based on problems. The sections in the computer are there for you to complete: "problem," "action," "outcome," again based on problems the nurses have identified.

Some hospitals have tick charts - vile.

I think the latter systems are infantile and often don't allow for you to document information that isn't necessarily linked to a problem.

I think such models have de-professionalised nursing. Lawyers or doctors for example don't document themselves with tick charts or by writing "Problem: Action:" etc. They simply write free text based on their professional knowledge and observation - like professionals. Nurses used to do that, and I'd be happy if we went back to that.

JadedCPN, BSN, RN

Specializes in Pediatrics, Pediatric Float, PICU, NICU. Has 15 years experience.

My favorite way to document is the way the facility makes me so that CYA rules apply.

RN-to- BSN, ADN, RN

Specializes in SCRN. Has 7 years experience.

My favorite way to document is without interruptions, but how often does that happen?