Charting Advice

lsyorke, RN · Jul 3, 2005

I use the age old head to toe! It's easy to remember and complete.

hope3456, ASN, RN · Jul 3, 2005

I'm getting ready to start my last year of nursing school and want to really get a handle on charting. I think if I can get some kind of organizational template developed that I can work off of until I can become more experienced and confident that would help me to make sure I'm covering key areas. Right now I just kind of freeze up when it's time to do nurses notes. Any suggestions on what to include?

I just graduated from ADN program. I know exactly how you feel! I got criticized on my charting. Some of the instructors i had made a very big deal about it, some weren't all that concerned. It doesn't seem like there is any right or wrong way to chart, and the different methods of doing so vary significantly from nurse to nurse. some overchart, some underchart. What matters is that you have covered your a$$ if you end up in court - that is what it all comes down to.

I personally had an instructor who was on a real power trip, and that was an easy way to criticize the students, was by tearing apart their charting.

I am not a real experienced nurse, so I'm sure others can give better advice, but some helpful hints I learned

Pretty much in any narrative address the following since they are important.

neuro status (A&O x 3),

oxygenation (resps even and unlabored)

pain levels - even pain isn't an issue, address it (and always ask about it) since it is subjective. I have heard this one can get nurses in trouble - not documenting pain status.

Denies - use this word frequently since it shows that you asked the patient if they were in pain - you didn't just assume (denies pain), needs anything (denies further needs), ect.

For liability, end narratives by "call light in reach and denies further needs." Make sure it is true, however.

If there is something out of ordinary, always document what you did about it.

Double charting - this is a hot potato issue - I personally don't like it- it is a waste of time. If you can document on an assessment sheet that "lungs were clear"(and it is not an issue for that pt.) why write it in the narrative. Some nurses feel they are covering themselves better by this and always "double chart" - some don't. Ask your instructor what she thinks and do it her way to make your life easier. However, if the pt. has issues that are out of the ordinary, such as fall risk, confusion, ect. Make sure you address what you did to prevent the fall, ect. (side rails up x 4, bed alarm in place, ect.) That way, you are showing you know what issues the pt. is dealing with and that you are on top of them.

Never give your opinion in charting - keep it objective and to the point.

Calling the Dr. - always document what time and what you told him.(I knew a nurse who got in trouble on that one.)

just a couple pointers i picked up on. Also, read the other nurses charting to get ideas. It gets easier with practice. Good luck!

Altra, BSN, RN · Jul 3, 2005

Right now I just kind of freeze up when it's time to do nurses notes. Any suggestions on what to include?

Mariedoreen, does your facility utilize charting-by-exception? If so, this can guide what you write as a narrative note. For example - the assessment sheet at the hospital system where I had most of my clinicals contained a brief description of notable items in head-to-toe/system-by-system format. If everything in that system was WNL, you simply initialed the box. If something within that system was outside of normal findings, you wrote a change symbol (triangle) in the box with your initials, and it was expected that whatever was abnormal in that system would be detailed in the narrative note, along with any interventions done to "fix" that problem, or "physician notified" or "case manager made aware" etc. You can also include anything the pt. expressed concern about or any teaching provided.

Admission assessment notes always ended with "pt. oriented to room and call system. Call bell within reach."

HTH :)

Hairstylingnurse · Jul 3, 2005

I just graduated from ADN program. I know exactly how you feel! I got criticized on my charting. Some of the instructors i had made a very big deal about it, some weren't all that concerned. It doesn't seem like there is any right or wrong way to chart, and the different methods of doing so vary significantly from nurse to nurse. some overchart, some underchart. What matters is that you have covered your a$$ if you end up in court - that is what it all comes down to.
I personally had an instructor who was on a real power trip, and that was an easy way to criticize the students, was by tearing apart their charting.
I am not a real experienced nurse, so I'm sure others can give better advice, but some helpful hints I learned
Pretty much in any narrative address the following since they are important.
neuro status (A&O x 3),
oxygenation (resps even and unlabored)
pain levels - even pain isn't an issue, address it (and always ask about it) since it is subjective. I have heard this one can get nurses in trouble - not documenting pain status.
Denies - use this word frequently since it shows that you asked the patient if they were in pain - you didn't just assume (denies pain), needs anything (denies further needs), ect.
For liability, end narratives by "call light in reach and denies further needs." Make sure it is true, however.
If there is something out of ordinary, always document what you did about it.
Double charting - this is a hot potato issue - I personally don't like it- it is a waste of time. If you can document on an assessment sheet that "lungs were clear"(and it is not an issue for that pt.) why write it in the narrative. Some nurses feel they are covering themselves better by this and always "double chart" - some don't. Ask your instructor what she thinks and do it her way to make your life easier. However, if the pt. has issues that are out of the ordinary, such as fall risk, confusion, ect. Make sure you address what you did to prevent the fall, ect. (side rails up x 4, bed alarm in place, ect.) That way, you are showing you know what issues the pt. is dealing with and that you are on top of them.
Never give your opinion in charting - keep it objective and to the point.
Calling the Dr. - always document what time and what you told him.(I knew a nurse who got in trouble on that one.)
just a couple pointers i picked up on. Also, read the other nurses charting to get ideas. It gets easier with practice. Good luck!

:yelclap: :yelclap: :yelclap: You may not be an experienced nurse, but you sure know your charting like an experienced nurse. Great post.