I need help with charting!!!

[Peeker19]

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

[FLArn]

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.

[RevolutioN2013]

Pre-nursing student here with a question...I have been told that as an RN you are too busy to see a patient and then chart, and then see a patient and then chart. My question to that was to ask how on earth you can even REMEMBER everything 3 or 4 patients later! Do you have a recorder you speak into or do you write it all down in a pocket notebook or what?

[caliotter3]

People write it all down after their memory banks start to fail them with age. I guess it is feasible to use a recorder if your facility doesn't ban them because of HIPAA issues.

[Trubie, LPN]

"no voiced complaints" "no apparent distress", vocalized "blah blah blah"

and my favorite... faxed pharmacy, updated MAR, completed lab requisition, contacted family, family acknowledged, initial dose given.

We paper chart too... my hand might fall off soon!

[LVN_365]

I have been told to be very specific about PT/OT/Speech for skilled patients. Also, there are little handy medicare charting guideline books out there that a veteran nurse passed on to me...outlines each particular to include by condition/d(x)...very helpful if you can get your hands on one...