help with charting

Nurses New Nurse

Published

Help!!! We have computerized charting. We do every 4 hour assessments which is easy because it goes by systems, but we also have to do narrative charting in the computer. We are required to make a note in the computer every 2 hours and as needed, such as when a procedure is done or a doctor comes in. I am having trouble with this. I just don't know if I am charting how I am suppose to be charting. When things are happening with the patient it easy, but when your patient is relatively stable, I don't know what to chart. I have asked other people at work, but everyone says it will come with time. That's nice and everything, but that really doesn't help me. Any help would be appreciated.:wink2:

86toronado, BSN, RN

1 Article; 528 Posts

Specializes in neurology, cardiology, ED.

How about something like: "Patient is resting in chair/visiting with family/sleeping etc. In no apparent distress. Vitals signs WDL, call light in reach, will continue to monitor."

It will get redundant, but so does writing a progress note Q2hours. We chart by exception where I work, ie: only when there is a change in condition, a procedure done, or some type of incident involving the patient (falls, etc).

Pediatric Critical Care Columnist

NotReady4PrimeTime, RN

5 Articles; 7,358 Posts

Specializes in NICU, PICU, PCVICU and peds oncology.

My old standby is something similar. "Pt at rest, appears to be asleep. VS as per monitor. Left undisturbed." Or "Pt roused easily with med administration, settled per self post." You can select a sentence or two that doesn't really say anything but meets your requirement for q2h documentation.

A_Simp

69 Posts

Specializes in Tele.

You can also add "Safety being Maintained" :twocents:

Specializes in Med Surg, Ortho.

I was instructed to never chart that pt is asleep. Need to say, pt resting with

eyes closed.

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