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help with documentation


At my job, we have computer charting but we are required to make a nurse's note every 2 hours and prn such as for procedures. I really need to find a book that can help me with this process. Sometimes, I don't know how to put it into words and I want to do it correctly and give accurate and complete information. Does anyone know of a book that can help with nursing documentation?

Thank you

There are books out there. At barnes and nobles or online you can find something call Incredible Made Easy Books. There is one made for especially for documentation, it might help. good luck. If you do find something, let me know what you decide because I am a new grad, and looking for something like that too.


Specializes in ICU Nursing.

As a new nurse in a hospital with paper charting, it was a real shock to me the amount of charting we have to do. We also have to chart Q2h. Sometimes it's really hard to know where to start. And when you get behind because you are busy...forget it! I think it's something that comes with time. I will definitely look for some books though. I remember my teachers telling me that if I didn't chart it, I didn't do it. This helps me.

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