How to chart that everything is ok?

What's wrong with charting that? I work peds, and our standard of care is narrative documentation q2h minimum. (Yeah, right!) If the kid's sleeping and has stable vitals, is pink and warm, I chart, "Patient resting quietly in bed with stable VS. Left undisturbed." q2h for the whole night if accurate. Because our patients are all monitored, the only thing I might have to disturb them for is to take a temp or give a med.

You might want to add alert, oriented X3 to that (if true) as some postops can stroke out and look just fine till you try to rouse them.

I work on a Medical Unit. If my patient is stable I chart something such as this:

A & O x3, no c/o pain, respirations even and unlabored, VSS, no S & S of distress noted, will continue to monitor pt status

Remember K.I.S.S. from nursing school...Keep It Simple Silly! Hope this helps!

alert, oriented X3 to that (if true).

A & O x3,

To OP,

Don't forget to write this if working nights,only if it is true!! I had a classmate who got into the "flow" of this one, and got nailed for it.

2am-A &O x3

4am-A&O x3

etc....

Instructor was not too happy.

Ouch.

Pt in bed, resting, no apparent distress, no SOB or respiratory distress. Denies pain

I'm just not sure what to chart when everything is ok. What else would I chart?

Tomorrow is my second day on the job, med/surg. :) Thanks for any help you can give.

drop the no apparent distress, ( you can write the objects you see, the patients statements, but the word apparent was taught to me as a no no) exp: Patient in bed, patient denies SOB, and pain.vital signs stable.

I would err on the side of caution. Remember if it wasn't charted, it didn't happen. And that also applies if NOTHING has happened.

I usually still go system by system, or a head to toe charting the norms. It can still be a sentence or two.

Best of luck.

Pt in bed, resting, no apparent distress, no SOB or respiratory distress. Denies pain

I'm just not sure what to chart when everything is ok. What else would I chart?

Tomorrow is my second day on the job, med/surg. :) Thanks for any help you can give.

I always write no distress noted. I don't use the word apparant

Safety is a BIG issue. You would want to type, especially in your beginning narrative, something about safety.

Bed in low position, side rails up, bed brakes locked and call light (and pca button if applicable) within reach. Instructed to call for assistance, pt verbalized understanding. Will continue to monitor.

You don't know how many times I've gone into a pts room and there bed is in the high position and they didn't even realize it. I went into a room yesterday, put the bed in low position, the pt said, "Oh my gosh, thank you so much, I didn't realize my bed was so high". She had a bedside commode at her bedside and did not have a steady gait.

That is another thing you want to chart. If you see them walk. Pt ambulating on floor with steady gait. Goodluck

Vss/nad/aao X 4. Will Monitor

Thats What I Chart

I would also document s/s of their admitting diagnosis. If they are there for cellulitis, address the condition of the skin. If they are there for pneumonia, address respiratory. You get the idea! Even if there is no change and everything seems fine, they are there for something, so it should specifically be addressed. Hope that helps!

Complete head to toe every shift...then update pain or other issues as needed...

at 2AM, I would chart "vital signs(and what they are...stable is different to different people and patients t/p/r/bp/ox%), breathing regular, eyes closed, no apparent distress, patient showing no s/s of pain.