I lack charting skills

Antikigirl, ASN, RN · Oct 17, 2004

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

THIS BOOK IS THE BOMB!!!!!!!!! Must get!!!!!! oh yeah...I agree! LOL!

And I also do this little reminder....if I DON'T chart it...it never happened..let that rule your judgement. If you find it is worth mentioning CHART IT! Let others be darned (although that isn't nice or helpful), it will save your keester and your patients later on if it was to become an issue later! I have all my Caregivers chart everything..and it has saved 8 in one year from hurt when a patient gets confused and accuses them of something they did not do!

Trust me...chart it if you find it will help others to understand, or help you! Heck...think of the times where some seemingly unimportant information wasn't told to you..but made a huge difference or tons of time figuring out~!?!? Could have been solved by saying something about it in writing?!?!?!?

In fact, I go through the charts of my entire facility to point out lousy charting (and it is so good now!!!!)! And 9/10 they simply didn't chart! I even give them immitation trial summons and it all...and lets say..charting far surpasses my state now! NO, I don't let it go overly..infact I give fake summons for that too...saying "looks like a cover up!"...(okay my imitation summons are kind of a light hearted deal..but it makes them think...it is actually titled "you have been summoned to the superior court of ____ (my name) court...so what's up????" That gets giggles and thought really!)

Oh crud...I guess I should have gotten into law.......NAAAAAAA~! I like HELPING! LOL!!!!!

In other words..chart or it didn't ever happen, and that can bite you on the...ummmmmm..insert area here! Your instict will tell you..and in the case of doubt...do this..chart it!!!!!!!! LOL!!!!!!! (just be professional doing it!!!!)...

autoris · Oct 18, 2004

There's too much paperwork!

autonursis · Oct 18, 2004

Paperwork is a problem!

JamiRN · Oct 18, 2004

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."

I like that. WWWWW&H. When I started out, I used the SOAP method, it was a way to get your thoughts organized. Some say, I chart too much. I have to admit, I'd rather chart a little heavy than miss something. I once had someone tell me after reading my charting, "hey, I'm not buying the book". AND on the other side, I sent my nursing assessment note to the MD because overall, the pt was a mess. The MD called me, thanked me for my "excellent and descriptive information". Goes both ways.

dazzle256 · Oct 18, 2004

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

Did your DON say exactly what was missing? Nightngale was right charting correctly can and will save your skin. Some of the books mentioned would probably be a good start another thing you may consider is looking at other nurses charting... see how they do things.

MikeLPN · Oct 18, 2004

I bought Chart Smart and it helped a little and I try to read some of what the other nurses chart when I can which seems to help more.

One time I charted "Bed hold policy not sent because the ambulance would not stop even though I was running after it in the snow and banging on the door for them to stop." :chuckle

I guess you just do the best you can, educate yourself about it, see how others do it better and you gradually improve. Make it legible :stone and keep it simple. After you get in so many situations your brain just makes standard templates and you fill in the blanks as you go. At my last eval the DON said I had gotten a lot better

nuttyRN · Oct 18, 2004

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

I HATED charting at first, when I started nursing school, but I realize that it will save me if, god forbid, I am ever involved in a lawsuit. (knock on wood) I really learned to chart well after nursing school, mostly by familiarizing myself with the style of charting. We use "exception charting" and flow sheets. I read as much charting by other experienced RNs as I could and then learned to pick and choose what I liked. It sure is a learned art though. When in doubt, I use as many exact pt/family quotes as possible to help describe the situation. Also, never use words that are subjective - that means no using "appears" "looks like" etc. Anything that makes you sound like you don't know what you are seeing/talking about is not good (to the lawyers!). Good luck, you will get it down - it is something that does take time!