guest1154907 2 Posts Aug 16, 2020 24 people have looked at this and no one is answering my question...
Loco-Bonita, BSN, RN 65 Posts Specializes in CVIMCU/CVICU. Has 6 years experience. Aug 16, 2020 Maybe you could elaborate on your question, as it is very vague and difficult to answer in its current formate.
Sour Lemon 5,016 Posts Has 13 years experience. Aug 17, 2020 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 7,899 Posts Specializes in NICU, ICU, PICU, Academia. Has 46 years experience. Aug 17, 2020 OP: Your question is so vague. If 24 looked without answering, perhaps it's the question and not the audience. Throw us a bone.
JKL33 6,594 Posts Aug 17, 2020 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 554 Posts Specializes in Oncology, ID, Hepatology, Occy Health. Has 37 years experience. Aug 17, 2020 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 1,476 Posts Specializes in Pediatrics, Pediatric Float, PICU, NICU. Has 17 years experience. Aug 17, 2020 My favorite way to document is the way the facility makes me so that CYA rules apply.
BSN-to-MSN, ADN, BSN, RN 398 Posts Specializes in SCRN. Has 9 years experience. Aug 23, 2020 My favorite way to document is without interruptions, but how often does that happen?
