Help with Progress notes

Hello, I am 6 months into being a RN on a cardiac floor. I love my job, Im looking to improve my nursing notes. Any suggestions? For example, for GI I put bs, po intake, fsbs info, any n/v..etc but I feel like it isnt enough info, does anyone have any suggestions for good charting/questions to think about for each system? Thanks for any help!

Well, here is what I do. We have computer charting for reassessments, but depending what kind of form I am filling out I have to chart by body systems.

Neuro - A&O x?, PERRLA ?, pupil size ?, grips/pushes?

Cardio - what kind of rythym, cap refill time, radial and pedal pulse strength, pacer and what kind, is pacer pacing?

Pulm - lung sounds ? , sputum characteristics, O2 settings and sats

GI - bowel sounds, abdomen soft or firm, tender or nontender, obese, flat? diet

GU - foley or urinal ?, urine color and quality, bm and characteristics?

IV - what gauge and where, PICC or central, drips, maintenance fluids at what rate?

Skin - wounds, dressings, bed sores, pale or ruddy?, warm or cool, clammy or dry?

I am sure I have left out something

I would recommend starting from head to toe; using the same format with every documented assessment EVERY time you document. That way it becomes 2nd nature & (hopefully) you include everything, everytime. Be objective, B-E objective.:pumpiron: