helps for charting.

aquaphoneRN · Dec 27, 2005

Ah, I'm so glad this subject came up. I'm in a similar situation. I'm also a rather new nurse (less than 2 years) and work in the ED. I was pondering the same dilemma at work just today.

My ED also doesn't have "check-off", "tri-fold", or any other type of assessment tool.

Our assessment tool is a blank piece of 8.5" x 11" ruled carbon paper.

Keep in mind this is a major New York City hospital! We're in the dark ages in NYC!

Anyway, if you read most of the literature on what constitutes proper documentation, the general rule is, honestly, that you're supposed to chart everything, and I do mean everything.

However, in a busy ED this is not realistic. In fact, it's quite impossible. Often you can't dedicate more than 5 - 7 minutes to charting, if that, so please people, I beg you, give REALISTIC advice, not textbook advice!

I've been trying to focus on just the chief complaint(s), my actions, doctors actions, and responses.

Example: 47 y.o. male comes in with chest pain:

Received pt @ 10am, A + O x 3, c/o mid-sternal CP 8/10 started "this AM" about 4 hours ago, non-radiating. No SOB. No Palpitations. EKG done, reviewed by MD whoever, pt. placed on monitor, o2 2L NC, HL # 18 R AC, cardiac set drawn and sent. Bedside troponin negative. Seen by MD whoever. NAD. aquaphoneRN RN. ---------------------------------

I would probably attach a strip from the monitor at the bottom of the page.

So there, it's short, it doesn't read like a complete history, and it doesn't tell you much about what the patient doesn't have, for example, I didn't say "no headache" or "no dizziness" or "no blurry vision", but if I have to list everything the patient doesn't have and their complete history, I'll be there all day. It DOES list every intervention I've taken, that the MD is aware, and what complaints/s+s the patient DOES have.

If a lawyer wants to argue that I didn't write "pt. has no headache" I can always argue, I didn't white it because it wasn't there.

If you have no tools and no computers, you have to be short, to the point, focus on the chief complaint and list your interventions and doctors awareness. Anything more is totally uinrealistic in my opinion.

Hope that helps. Look forward to hearing from other ED nurse on this, whether or not you agree, your perspective is welcomed and appreciated.

candyndel · Dec 29, 2005

Always, always, always do a head-toe at the beginning of your shift (and I dont mean on the new ankle that just got here an hour ago...) then prn. Especially if you have the 'hold' problem that we do (usually about 20 every morning with over half for ICU or CCU)!

You'll be surprised at what you might find that's different than in the report you got...but you also might see a red herring or two!!

Remember (among other things) you are getting paid to assess/monitor the patient and report changes in assessment. You arent charting to verify how your day was spent....I can not believe my eyes when I have to review a chart that looks like this:

700a Rec'd report

715a ECG done

720a NTG 1/150 given SL.

725a #18g to Left AC. labs sent.

730a ASA 325mg po given.

740a PCXR done.

750a ECG repeated

755a Plavix 300mg po given. Cardiology fellow at bedside.

AHHHHHHHHHHHHH!!!!!!!!!!!!

Those activitites all have their place in the record, but a scribe could do this!

I also suggest reading the notes of the shift(s) before you. That always helped me to learn what to look for and how to say it.

Good luck- once you have it down- your probably go to EMRs anyway :)

aquaphoneRN · Dec 30, 2005

Always, always, always do a head-toe at the beginning of your shift (and I dont mean on the new ankle that just got here an hour ago...) then prn. Especially if you have the 'hold' problem that we do (usually about 20 every morning with over half for ICU or CCU)!
You'll be surprised at what you might find that's different than in the report you got...but you also might see a red herring or two!!
This is really good advice, and I try to do this, but I just don't have time to document it all. In my ED we don't have EKG techs, we don't have nurse's aides or ED techs the majority of the time. We don't have IV start kits. We often don't have working BP cuffs/monitors. We don't have computerized documentation.
I feel like I just don't have time to document everything I should, so that's why I just do a more fucused assessment. Of course, the sicker the pt. the more I will try to document.
Documentation, to me, is perhaps the hardest part of nursing. There is a constant fear of omission, yet I don't have time for inclusion.

susi_q · Dec 31, 2005

Typical charting in our ER ...

**symptoms related to chief complaint.

**assessments with subsequent interventions.

**I ALWAYS note when i take over the care of a patient ("care assumed") and do my own assessment (noting any changes from prior), then if there is a problem that started before it got there, i've done what i could to cover my a**.

a lot can be said in a few words if you concentrate on why you are doing what you are doing.

Jen2 · Jan 1, 2006

Received pt @ 10am, A + O x 3, c/o mid-sternal CP 8/10 started "this AM" about 4 hours ago, non-radiating. No SOB. No Palpitations. EKG done, reviewed by MD whoever, pt. placed on monitor, o2 2L NC, HL # 18 R AC, cardiac set drawn and sent. Bedside troponin negative. Seen by MD whoever. NAD. aquaphoneRN RN. ---------------------------------

I do this also but I add an ABC + Neuro assessment + focus assessment

I usually start out with my focus assessment, then move on to neuro and ABC's.

1300: Pt brought to room 15 cc: midsternal chest pain 5/10 started "around noon" non-radiating no relieving factors aggravated by deep breathing, unrelieved by NTG x's 3 at home, - N/V. Cardiac monitor applied displays NSR in the 70's , O2 at 2l/min via nasal canula initiated. #18 gauge in LAC x's 1 attempt pt. tolerated well, labs drawn and sent, EKG and CXR at bedside. Dr. so and so aware and at bedside evaluating.

Then as I am labeling and sending my labs and the Dr. is assessing and the EKG and CXR is being performed I will go in and add.

1310: Pt. A&O x's 3 follows commands and appropriate. PERRL 3mm and brisk, hand grips strong = bilateraly. RR 20 shallow non-labored lungs CTA, O2 sat 98% on 2L via NC skin warm/dry/pink. NSR remains on monitor HR in 70's pulses +2 X's 4. Rates midsternal chest pain 3/10.

I will then document any changes through out the patients stay or just chart assessment remains unchanged.

aquaphoneRN · Jan 2, 2006

I do this also but I add an ABC + Neuro assessment + focus assessment
I usually start out with my focus assessment, then move on to neuro and ABC's.
I will then document any changes through out the patients stay or just chart assessment remains unchanged.

Hmm . . . I my opinion, your example represents very, very good charting. So in your ER, are you also lacking computers and essentially using a blank sheet of paper to chart?

angelique777 · Jan 2, 2006

i was having the same problem. i am in nyc and do have a check list and we also document some things on the computer. i was still having trouble with my nursing notes. wanted to be sure i covered all the areas in proper order. so i purchased nursing documentation handbook. i keep it in my bag. it has a good chart that list the syetems in order and when i admit a patient i just use that list to make sure i did not miss anything. it gives you an idea how to chart but in a nice concise form it fits all on one sheet once i copied it. it serves as a nice cheat sheet in my pocket. i made a copy of the chart from the handbook and keep with me. if i want specific things to look for based on certain conditions the handbook has more information based on patient condition .,

nursing documentation handbook third edition by tm marrelli there are other books but i got this one cause of size. if your in new york ........barnes and nobles on 18th street has a great nursing section and you can find other nursing documention helpers that you can browse and see if they are suited to your needs the handbook was helpful to me. it has a sample of a checklist as well. since your facility does not have one.

by the way what hospital do you work at in nyc. i do not find my facility antiquated was curious where did you work that it was like this.

any way good luck in the er i still waiting to hear from the er in my facility so i can start work there. i am in iccu right now .

wish you the best

angela

loricatus · Jan 2, 2006

nursing documentation handbook third edition by tm marrelli

do you know the isbn number of the book? what you have done sounds like a great idea. thanks

purplemania, BSN, RN · Jan 2, 2006

talk to your Education Dept. about the need for documentation that is simple: things you can fill in the blank or circle. Then talk to Risk Management about how hard it is to document. These are two depts that are very interested in your dilemma. There is probably a documentation committee but they will need input from the experienced ED nurses to make changes. Creating new forms is cheaper than defending yourself in court. Meanwhile, make a list of what is supposed to be on the chart and when. Type it up when you get home and go to Kinko's to get it laminated (unless you have one of those machines. A lot of scrapbookers do). Carry the guide with you. Sometimes seasoned staff forget what it is like for newbies.

angelique777 · Jan 2, 2006

I got the book through amazon.com

http://www.amazon.com/gp/product/0323010970/qid=1136238278/sr=8-1/ref=sr_8_xs_ap_i1_xgl14/002-9349072-2704051?n=507846&s=books&v=glance

that should take you right the book at amazon.com

hope it helps

Angela

angelique777 · Jan 2, 2006

NEURO:[/B] Pt recvd AXOX3 (1 2 3 Confused) Speech CLear( nonverbal, slurred etc)Pt has symmetrical strength and sensation with no paresthesia ( ex.or pt has weakness left side etc) . Pt pupils are PERRL, ( or pt has difference in pupil size or has afferent pupil defect etc) and gag reflex intac. Behaviour appropriate to situation. ( or not appropriate etc, calm composed, agitated, If patient has seizures etc)

Cardio: Vital Signs(apical hr, hear rhythm, BP, temp, PO2.pain: pain location type of pain, if radiating non radiating at rest with movement etc describe (0-10)) Are they wnl. as compared to pt baseline. IS Rhythm regular. If edema present ( +1, +2, +3 ....pitting non pitting location extremities , face, hands etc) Calf tenderness, if pt has any palpitations,Absence or presence of JVD. Absence or presence of Chest pain. capillary refil less than 2secs, +PPP equal bilateral

GASTRO: BS sounds + All 4Q.( or not if not what was done) ABdomen soft, nontender, nondistended. (note if bowel sounds active or not )Last BM (date and consistency if regular not regular, if noted any bleeding) Pain or no pain. Palpitations (as in AAA). IF they have N/V/D. Diet , lost of appetitie, weight gain.

GENTI: Voiding patterns (adequate amount, if clear, amber, cloudy, frequency, urgency,, dysuria, hematuria, or nocturia, Bladder distention present or not.

Skin: Skin warm, dry, intact, Color, (if not what the problem what the intervention) (describe size if ulcer present location etc type dressing if any place)

MUSCULOskeletal: Ability to perform ADLS(assistance needed, complete care, self care,) ROM, muscle strength, Steady gait, fall risk etc uses cane , walker, wheelchair etc

psychosocial:communication patterns, mood, effect, coping mechanism (anxious, agitated, violent, calm , composed, note if verbal encouragement provided) intellect Thought processes intact. PT has or does not have family support. Pt lives alone or has help. Pt ability to understand (is there a language barrierm, cognitive problem ( pt is slow to understand, is patient able to understand and comprehend instructions)

Peripheral Site: IV solution, is site intact, dry clean dressing, (iv Left AC #18g heplock infusing NS @ 75cc/hr site intact, no pain, no redness, no swelling pt has no complaint. will continue to monitor) ( should be change Q72hrs so note date inserted) ( same observation for Central lines)

Examples of modification to the above based on your pt problem.

Note for all of the above if any system has a problem note objective data and note intervention and note if improvement observed.

example pt tachycardic rate of 120bpm , PA Smith made aware pt given lopressor 50mg. Note pt heart rate improved hr now 86. or pt heart still tachy pt given bolus lopressor etc)

OR pt SOB PO2 87% room air. Pt placed on 2LNC nebulizer treatment given atrovent. PA smith made aware will continue to monitor. Pt PO2 now 98% with 2lnc will continue to monitor.

Pt anxious about procedure, pt explained what was going to be done . pt allowed to express fears verbal encourgement provided. pt states they understand. note pt less anxious now resting comfortable

PT has midsternal chest pain radiating to the left arm. Pt placed on 2lnc. PA smith made aware. Pt given sublingual nitro 0.4mg with no improvement in pain. pt rates pain =10. Pt given second dose of sublingual nitro.0.4mg......etc, pt noted some improvement. Pt placed on Nitro drip @ 8cc/hr will continue to monitor .VSS BP 120/80. hr= 90 will continue to monitor. PT chest pain relieved......etc.

So the above is modified based on your patient and based on whether the patient had a problem or not and what was done , who did you inform what did you do and how the pt reacted to the treatment.

I still consider myself a novice since not completed a yr yet in nursing so more experience nursing can modify. Not saying this is it for all your patient but it does give you and outline of all the systems and what your looking for as a guide and modifications made based on the condition of your patient.

Good luck

Angela