New graduate: need help with documentation!

[mizzLVN]

I'm a new grad and although I'm nervous about being a new nurse in general I'm worried about my documentation does anyone know websites or books that may be helpful?

[RedhairedNurse, BSN, RN]

Why does it worry you ?

I have found it helpful to go look at previous notes to see how other's document. I have learned one thing.....don't double chart. If it's charted in the medication computer, why type nurses notes???

[mizzLVN]

Well it worries me bc I was always taught in school CVA (cover ya ass) so I want my documenation to be close to perfect. I don't know maybe I'm just nervous about starting to work. I know I feel sort of confident in everything else but documentation is what I really get nervous about.

[BinkieRN, BSN, RN]

I totally understand your concern Here are some things I've learned along the way.

Record only the facts-what you can see, hear, smell, and touch. Do not be bias in your notes i.e. labeling a patient as a drug seeker, etc...

Never document anything in advance and keep your charting in chronological order timewise. If you forget something add it as a late entry.

When there is a problem identify it, describe the problem, how was resolved and the patients response to the drug, treatment, intervention etc...

Use any flow sheet, physical or computer, and fill it out completely.

Chart any conversations with a physician and the result of the conversation, change in orders, notifying physician of change in pt condition and what it is, the physicians reply. Don't be too wordy.

SN notified Dr.S of change in pt's BP. (BP will already be documented under vs) Dr. stated he would be in to see patient after office hours, no change in orders at this time.

[NeoNurseTX, RN]

I see double charting a LOT on my unit and have been encouraged to do it. What's wrong with it?

[mizzLVN]

Thks binkieRN your advice helped me ease my worries a little.

[NotReady4PrimeTime, RN]

I see double charting a LOT on my unit and have been encouraged to do it. What's wrong with it?

It's virtually impossible to chart exactly the same thing in multiple places. If the chart ever goes to court, and you've charted that you gave a med, or intervened in some way, in three different places and the times are even out by a minute, your credibility is going to be called into question. It should not be necessary to chart things in more than one place since a medical chart in its entirety is a legal document. To chart in your narrative that you drew bloodwork and sent it to the lab when the results of that testing will be recorded elsewhere in the chart is overkill. Obviously the bloodwork was drawn and sent, otherwise the lab couldn't have reported on it. The exception to this is whenyou give a PRN med, like morphine. You need to chart that you gave it and whether it had the desired effect.