How to chart 101? Components from top to bottom?

jammin246RN · Mar 12, 2011

Start with your assessment and VS. Assessment top to bottom so you don't miss anything :)

brownbook · Mar 12, 2011

In most charts the vital signs are on a graphic flow sheet so do not need to be written down as part of the nurses notes?

If you do chart (write down) the vital signs as part of your written nurses notes I can't think it would make a big difference which way you did it? Look at how co-workers, more experienced nurses, chart, maybe where you work there is a preference?

I am glad you are excited, you sound like me when I first started, obsessing over the smallest detail!!!! Try to relax and don't sweat the petty stuff.

tiroka03, LPN · Mar 12, 2011

I hand a list of vitals to be taken to the CNA's. I then take my equipment and assess and will do more vitals as needed. Now I have 60 pts on a (LTC) but many of them are IV AND GT and Medicare. I have at least 25 vitals needed, but a lot of them are twice a shift. (only for nights). I look at the pts when I first walk in, before report. There it's done for now. I take report and pass the midnight meds, and do all gtube and iv care and dressing changes I can get done. Of course if anyone is sick, I hit them up first. I then look at the vitals and do as much computer charting as I can. I get ready for the labs, get all my UA's, stools, and swabs done. I get all the computer stuff ready for the lab person. I then start medicare charting, and daily charting. I get everything ready for my early diaylsis patients, and check for appointments. Then I do 24 hour reports, and census, ect. Then I do chart checks on all 60 charts, doing redlining and calling for xrays, and things of that nature. I type in orders, others so conviently forgot. I then do daily things like fridge temps, crash cart checks, stocking the carts. Then I start looking at accuchecks - have about 28 of them, more on certian days. Before you know it, time to make another med pass, 4am. Then another one with accuchecks at 6am. Have to be done by 7am, when all the day shift comes in and expects perfection. I give it to them - perfection I mean. ha.

My advise is to think through your shift before you get there, and get a plan in your head. Work your plan, and fit in all the variable once you get there. Everyday it will be a new thing.