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Discussion

Home shift Charting

im in a bit of a dilema i work as an lvn for a child with sma and they require me to do narritve notes. they tell me that my notes are repititive but his condition never changes and i do the same thing everyday the only thing that changes are his vitals and the number of diapers he goes through during my shift what am i to do please hlp

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    Change something about your charting most every shift. One day change the diaper before charting your initial assessment, the next day chart the assessment first. Find something different and chart it. For example, blah blah, assess blah, blah, "noted loud,audible congestion. Suctioned trach blah, blah." Another area for different charting is patient education. You aren't going to chart that you provided education about handwashing every day. Look for different patient responses to care provided. If he grimaces during bathing, chart that, and note when the patient seems to have relaxed. Go to the shift with the mind set that you are going to find something different to chart about, no matter how small or unimportant.

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    i do chart small changes like that but over all they still tell me im doing the same thing. i tried rearranging my notes but his plan of care tells me what to do and thats what i do i do note change in condition but that rarely happens and for narratives it gets pretty redundant but thatnk you ill try doing that during these notes anything better then charting hourly

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    when learning how to chart in school, I looked at many different styles of charting by lotsa different nurses. there are many ways to say the same things. get a book on charting, learn some new styles, new words, new observations. look at some charting styles of fellow co-workers. ask your supervisors for ideas. what would they like to see? just telling you that you are being repetitive is not being very constructive.

    be creative.

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