Help with charting?

tewdles, RN · Oct 31, 2009

Try thinking about it this way...your charting is how you communicate what is going on with your patients. Sometimes flow sheets give you the vast majority of what you need to know...sometimes not so much. Ask yourself this...if you were following yourself, what would you need to see in the documentation to help you out with your job? Additionally, if there are any abnorms or changes reflected on the flow sheet, consider whether you should clarify your findings in a narrative. Remember that your documentation is your protection as well as communication. There is no reason to be redundant. Just paint the picture.

Lola77 · Oct 31, 2009

I think I am so scared of saying something that I shouldn't - I heard so much in nursing school about not writing opinions, etc. Like, for example, if I were to find a patient on the floor covered in blood, I could not write "patient found covered in blood" I would have to write "patient found covered in wet sticky substance" (that is an example from my GN class) so I find myself scared to write anything.

The really sad thing is that I used to be a technical writer and I was an English major so you would think this would be the easiest part of my job! lol!

tewdles, RN · Oct 31, 2009

Oh for pete's sake....if you are quite sure that the patient has blood on her face say so...imagine how being wrong about that puts either you or the patient in peril....uh...it does not. Clearly you should not assume anything, however, if it looks like a horse, runs like a horse, smells like a horse...it is probably a horse and not a zebra.

RockyCreek · Nov 1, 2009

I wouldn't have problem saying:

'Patient found on floor at foot of bed with blood on left arm and hand. IV catheter intact and on floor next to patient's right hand. States "I was washing the car and got all these wires stuck on my arms"

In this way, I have stated just the facts, offered no opinions, but I have told you that I suspect he got confused, got out of bed, fell/slipped and removed his IV.

tewdles, RN · Nov 2, 2009

Reminds me of a case in the PICU years ago....kid fell approx 20 feet out of a tree...belly case...vomited bright red emesis in the unit. Young RN caring for kid freaked out...."oh my god, he's bleeding out"...experienced nurse checked emesis and found heme negative, child was climbing a cherry tree getting to the "good ones"...looked like he found quite a few good ones...lol

Moral to this story...if you are not sure it is blood, check it. Otherwise, just describe what you see and hear in your documentation...no need for your opinions or assumptions.

nurseiam08 · Nov 6, 2009

The book Nurses Guide to Clinical Procedures by J. Smith-Temple and J.Young Johnson has very good examples of documentation for all the nursing interventions.