Favorite type of documentation style?

What’s your favorite way to document

Edited Aug 16, 2020 by Nurse1276

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

[Loco-Bonita, BSN, RN]

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

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]

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]

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]

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

[RN-to- BSN, ADN, RN]

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