How and what book did you use to learn charting nurses notes?

freebirdRN86 · Mar 12, 2011

Are you in nursing school? These are all things you learn in class and clinicals. And Every institution is going to be slightly different in the way they chart and such.

tiroka03, LPN · Mar 12, 2011

You learn from repetition. Find out what things are most important to chart. For instance, if I notice someone with a cough. I would want to chart lung sounds, if the cough is productive, vital signs, o2 sat, if they need o2, if I gave it to them, what is their sat on 02, did I call the doctor, did I get new orders, what were the results of the orders being carried out.

If I were charting on getting a UA, I would chart that I got it, and then I would chart on the color of the urine, and if I cathed them, I would chart of that as well.

Each thing you do, you chart your brains out, so someone can't come up with the idea you didn't do this or that thing. It's a way to document, but also a way to protect yourself as well.

LegzRN · Mar 13, 2011

I like your enthusiasm, but how many new threads are you going to make about charting?

hiddencatRN, BSN, RN · Mar 13, 2011

I didn't learn it from a book. We learned it in clinical and then as a new nurse I've learned how to chart for my employer.

FutureRN9 · Mar 13, 2011

i have learned most of my knowledge from just doing it. my clinical instructors started from the very first clinical and now that i have just finished my last clinical i'm much better - definitely not the best though.

for a general note i like to keep it basic and simple:

1)note their loc - a&ox4 or confused and disoriented, etc

2)note their respiratory status - respirations e/u, no s/sx of distress, etc) 3)what was their skin color, temperature and integrity?

4)what did you do for them? - talked to them, vitals, therapeutic communication, education, etc.

5)requests - states no needs or wants ..

6)safety - siderails up x2, bed locked and in low position, call light within reach, bedside table within reach, encouraged to use call light for assistance.

7)continuation of care - will continue to monitor, will return for hourly rounds, etc.

for an assessment: i like to remember to work from the head down.

1)brain = loc.

2)eyes - perrla?

3)ears - you may not do a diagnostic hearing test, but note if they have any difficulty hearing you when you speak

4)nose - if it is pertinent to the patient's dx

5)mouth - look at the color, condition, odor, teeth, throat and gums

6)neck - rom, lymph node assessment, pain, bruit

7)breasts (women) - you may not always assess the breast, but if you do then include your findings

8)abdomen - bowel sounds x4, tenderness, distended, hard/soft ..

9)genitals - again, you may not always assess the genitals, but if you do document your findings

10)musculoskeletal - rom, pain, contractures

11)skin - integrity, color, diaphoresis ..

12)waste - if pertinent to the dx, include urine or stool assessment

13)pain - very important!! easy way to assess and chart pain is by using the acronym pqrst. (i'll put something about that at the bottom)

**every institution is going differ on their charting requirements; some will have you enter an assessment separately and you can just reference it by saying, "head to toe assessment completed, see assessment tab". it is much better to over-document than to under-document. the worst thing that is going to happen is that a doctor is going to get upset because you're too wordy :) but at least you'll have a good record to reflect on what went on with that patient during your shift!

okay, now on to pain!!!!

#1 - always remember that pain is subjective. your patient is the one in pain, not you, so you can't tell them how if feels.

#2 - it is not an unknown fact that there are people that will come to the hospital only to seek medication. so what do you do?? you give it to them!! if the doctor prescribes it, then you have to give it. it is unethical to withhold ordered pain medication because you feel the patient is only seeking medication. instead, use the opportunity to educate the patient on drug rehabilitation and drug addiction. it's also important to remember that withdrawing from medications can be life threatening and very dangerous - so it should be done in a monitored and safe environment.

#3 - assessing pain .. like i said, use pqrst

p - provokes: what causes it, makes it worse? also, what makes it better?

q - quality: describe it to me. dull, aching, sharp, stabbing ...

r - radiates: does it start somewhere and then go somewhere else?

s - severity: rate it on a scale between 0-10, 10 being the worst pain you've ever had. (some people say 1-10, i prefer 0-10 because then you are allowing the patient to say they are having zero pain)

t - time: when did it start, is it worse at certain times during the day, is it better during certain time of the day?

**sometimes there is also an o before the p and this stands for onset, but this can be covered within the time assessment.

another option is using a soap note. this includes breaking your note down into 4 sections: subjective, objective, assessment and plan.

1)subjective - what does the patient report or say?

2)objective - what are your findings?

3)assessment - quick generalized summary of the patient.

4)plan - what is the plan for that patient. dr's plan and your plan.

here is an example - this isn't the greatest example, but i found it on the internet. [http://en.wikipedia.org/wiki/soap_note]

s:no chest pain or shortness of breath. "feeling better today." patient reports flatus.

o:afebrile, p 84, r 16, bp 130/82. no acute distress.

neck no jvd, lungs clear

cor rrr

abd bowel sounds present, mild rlq tenderness, less than yesterday. wounds look clean.

ext without edemaa:patient is a 37 year old man on post-operative day 2 for laproscopic appendectomy, recently passed flatus.p:recovering well. advance diet. continue to monitor labs. prepare for discharge home tomorrow morning.

sorry this have been such a long note. i hope it helps someone, even one person would be wonderful .. isn't that what nursing is all about?? :)

steelydanfan · Mar 13, 2011

Many new grads have this question because they are not allowed to chart on computer systems, and they don't get the practice. They SHOULD be doing written practice charting as part of thier clinicals; but if they are apparently not even being taught the reasons for mobilization, this probably is not happening either.

Learn SOAP. This formula is the best and most comprehensive tool for charting.

mel7990 · Mar 13, 2011

yes. for me all books are good, all you can do is to apply what have you learned in the classroom and in your related learning experience .if you know how to assess i think, you can be good in charting, charting is a legal document first.