I need help with charting!!!

So here is what I normally chart....please any feedback would be greatly appreciated

A+oX2

Verbalizes need or staff to anticipate all needs, HOH or Aphasia, Deaf Blind etc

HRR, no c/p, no edema

LSC or LS Diminished, no sob, no cough

Cont or incontinten, foley patent cl yellow urine or whatever color

+bs x4 No NVD

2 assist

5/10 pain scheduled vicodin given, or whatever PRN I gave the and if the result was + or -

All equipment- WC, FWW, nebs, G tube, Picc line etc

Turgor fair, then if they have bruising or anything else skin related

Coccyx- Intact or open and calmoseptine for tx

Heels- Dressings or red, soft granulex applied.

Then if they are on COC or ABX I write a note like: Pt continues on Flagyl for C-diff, No signs or symptoms of adverse reaction.

Where can I improve and what am I missing??? I personally think our paperwork sucks and does not prompt you to remember anything

For pain you should always doc location and quality: dull, sharp, shooting, etc

For no CP you should put, "denies chest pain."

Hope this helps

SyckRN

Thank your for your reply!!!! I will for sure start adding those things to my list of what to chart... I am just trying to improve. I am always hearing second hand that our charting is bad....Nobody has even come up to me and said anything about it but I always feel there is room to improve :)

Charting is my downfall. I have a strange belief that I'd rather spend my time actually taking care of the person than writing about it. I take so much time on my rounds that I have little or no time to chart! I hate it. Wish I could have someone follow me and do the charting for everything I do. LOL

I know right....12-17 skilled residents and all of them have to be charted on....and all of them are on ABX or having behaviors that need to be charted....oh and don't get me to the having to chart on it in the hard chart and in the nursing assessment chart....yes you heard it two seperate charts so basically all day I am triple charting because if it is a med it has to be charted no the MAR as well......SUCKS to be on paper still...seriously can we get with the times here....I mean our suction machine from before WWII is ridiculous and embarrassing to be bringing into patient rooms.

We have to chart last BM either pt report or PTA.

Then if they are on COC or ABX I write a note like: Pt continues on Flagyl for C-diff, No signs or symptoms of adverse reaction.

Where can I improve and what am I missing??? I personally think our paperwork sucks and does not prompt you to remember anything

With antibiotics you should chart the signs/symptoms. Such as for UTI no dysuria, urgency or frequency. Or for c-diff. number of BM, quantity/quality.

Safety precautions maintained

With antibiotics you should chart the signs/symptoms. Such as for UTI no dysuria, urgency or frequency. Or for c-diff. number of BM, quantity/quality.

Ok that makes sense but I usually chart that where I do NV and the I put like for C-diff diarrhea on flagyl for C-diff pt had 4 loose stools this shift, so should that also be in the narative as well?

hello

CBWR = Call bell within reach

You may also want to chart how much of each meal was consumed...

If the patient is skilled rather than custodial care you should chart something about the reason they are skilled e.g. for a hip replacement you would talk about the surgical site and the site care and whether or not they are working with P.T., the weight bearing status, the level of assist needed with ADL's etc.