Skip to content
View in the app

A better way to browse. Learn more.
allnurses

A full-screen app on your home screen with push notifications, badges and more.

To install this app on iOS and iPadOS
  1. Tap the Share icon in Safari
  2. Scroll the menu and tap Add to Home Screen.
  3. Tap Add in the top-right corner.
To install this app on Android
  1. Tap the 3-dot menu (⋮) in the top-right corner of the browser.
  2. Tap Add to Home screen or Install app.
  3. Confirm by tapping Install.
Discussion

How do you document what you have done?

I'm curious as to how you document what you have done like giving injection or taking vitals? Does any one have any examples? Thanks:)

Featured Replies

Injection goes on the MAR....we just sign in the little box to say it was done & went well

Vitals just get written on the Vitals record sheet. Numbers, no description. Unless theres something to note, then it goes into the Nursing notes with ur assessment findings.

  • Experts

I just did my first acute care placement and we had to do computer charting.Vitals had places for info like what kind of thermometer,what position were they in, which arm etc.For bp it asked what kind of cuff and again what position they were in.For respirations it asks if resps were labored or non-labored. I know for paper charting you just record the numbers.

I'm curious as to how you document what you have done like giving injection or taking vitals? Does any one have any examples? Thanks:)

Are you refering to the Nurses notes? If so here is what we are being taught.

1800 B/P 136/84 P 78 T 99.3 R 15 o2 96% reports resting comfortably

then we just sign it J.Doe SN/SU---------------------------

I "believe" that the MAR is the only documentation of record for administering meds.

Does this help?

  • Author

Yes, it does help. Thank you so much!:nuke:

We were taught to document any PRN meds given in the progress notes as well as response to the med.

We were taught to document any PRN meds given in the progress notes as well as response to the med.

You are correct, we are being taught to document PRN meds as well, because they are not "regularly scheduled" meds.

Guest
This topic is now closed to further replies.
Go to topic listing

Currently Reading 0

  • No registered users viewing this page.

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.