Charting

mitchsmom · Jul 3, 2005

When I was first writing assessments/charting, I used my Assessment clinical guide as a guide...it lists normals and abnormals and I'd just pretty much copy the appropriate phrase:

http://tinyurl.com/dysnb

I added in whatever the pt had been doing & whatever procedures, & anything else that I thought was important or relevant... sorry that's so vague, I'm sure you were looking for more!

I also take this sheet with me as a basic guide & I've done pretty well with it:

http://tinyurl.com/b84qr

(you will need to sign up for the yahoo group to get to the files; there are tons of other files there that you may find helpful too):

http://health.groups.yahoo.com/group/allnursesstudents/

My last two rotations have had computer charting and there isn't a lot to have to write on your own because you fill in the pre-made charts/assessments on the computer & only write if there's something not listed. I'm getting better but it was really hard to come up with something to write at first, I had to ask my instructor or nurse all the time & I still do a lot!! :)

Here are some charting books at amazon, but none of them have ratings... would like to hear if anyone has any of them!

http://www.amazon.com/exec/obidos/tg/detail/-/1582551774/ref=pd_sim_b_2/103-1493977-3639827?%5Fencoding=UTF8&v=glance

http://www.amazon.com/exec/obidos/tg/detail/-/1582551642/ref=pd_bxgy_text_1/103-1493977-3639827?v=glance&s=books&st=*

http://www.amazon.com/exec/obidos/tg/detail/-/0874349524/ref=pd_sim_b_3/103-1493977-3639827?%5Fencoding=UTF8&v=glance

http://www.amazon.com/exec/obidos/tg/detail/-/0323010970/ref=pd_sbs_b_3/103-1493977-3639827?%5Fencoding=UTF8&v=glance

http://www.amazon.com/exec/obidos/tg/detail/-/0323004318/ref=pd_bxgy_text_1/103-1493977-3639827?v=glance&s=books&st=* (rated 5 star by one preson)