I lack charting skills

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So says my DON. Anyone know of a simply written book or site so I can improve?

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Figure out your plan; whether the facility uses charting by exception, DAR, or SOAP etc.

Do not reinvent the wheel, it is good you came here for help. Charting should become a natural course throughout the day. I used to dislike charting but now I realize how it has saved my butt over the years and helped the pt by providing a tool for the other staff to give the pt continuity of care.

I hope this is the start of something positive for you. ;)

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Specializes in oncology.

I am right there with you! I am a new LVN and my charting skills need help. I have not seen a book on charting but, I would love to find one.

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Specializes in Med-surg; OB/Well baby; pulmonology; RTS.

Nursing Made Incredibly Easy has a book about charting. It is a great book! You can usually find it at your local book store.

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I agree with the books but, I would also ask your DON what her definition of good charting skills are and for an example. You may or may not "lack" the skills-it's subjective and you need to know her criteria-especially if she is signing your pay raises!!

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Review your facilities policy on charting, and your governing body (BON, etc). My one nursing instructor had so many practical ways of doing things without complicating it - great source of advice. Her suggestions were to chart according to body systems - start with CNS and work your way down. We chart by exception so if there is nothing to chart R/T a body system, you skip that one (unless it is a new admission in which case you should chart on each body system just to CYA). When charting a procedure - I always remember to include "who, what, when, where, why, and how." So, an example would be "April 2nd, 2003 @ 1100 - Pt. requested and received i po percocet tablet for 7/10 breakthrough back pain as per physician's prn order and hospital policy." And then (because you should chart results), "April 2nd, 2003 @ 1140 - Pt. states pain relieved to 1/10."

But, always refer to your governing bodies guidelines as to documentation. My governing body is the College of Nurses of Ontario - I follow those documentation guidelines.

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Chart according to the care plan. It'll keep you on track.

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Nursing Made Incredibly Easy has a book about charting. It is a great book! You can usually find it at your local book store.

The whole Nursing Made Incredibly Easy is great! My students and new hires love them!! They are easy to read and get to the point. There is no such thing as truly EASY nursing, but these guides take some of the intimidating stuff and make them more understandable! I got the whole set and have gotten rave reviews from student etc who have used them for reference!:)

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Oh! Yeah -- forgot to mention that our facility has a policy which spells out specifically what the minimum required documentation is for each unit. We also have computerized charting and have some built-in reminders to assist staff with complete and accurate charting ! The nurses here love it -- it took some getting used to , but it has been very helpful!

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Specializes in Family.

There's a book out called Chart Smart. I liked it fairly well.

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here is another book, charting made easy, it's part of the nursing made easy line. here is the link for amazon.com http://www.amazon.com/exec/obidos/tg/detail/-/1582551642/qid=1098041377/sr=8-4/ref=sr_8_xs_ap_i4_xgl14/102-2163346-1628120?v=glance&s=books&n=507846

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The problem you highlight is at the heart of nursings problems. Documenting or charting is not just writing things down, it actually defines nursing as a practice. Nurses continue to have a problem with it because nursing theory, diagnosis, plans and pathways are such rubbish and fail to define nursing in a practical, useful way. I believe I have solved this problem see my web site.

If you study the clinical examples cited you will develope the skill to accurately assess and document your care. Basically using the following method:

*ASSESSMENT-ANALYSIS

*CONSTRUCT-CARE

*EMPLOYMENT-EVALUATION

Use this like the SOAP format, except you will find that the ACE logic fits nursing practice much better. The aim is to paint the picture (construct) in any given clinical situation. Good Luck Paul

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