I need help w/charting please........

SouthernLPN2RN, MSN, RN, APRN, NP · Oct 27, 2005

I am a student & not sure how to chart. It seems if I include something my instructor says I should not have & if I didn't......then of course I should have!
This is an ex. of what I charted & it was wrong any advice appreciated.
0730-Assumed care. Assessment complete. Resting in bed, semi-fowlers position w/eyes open. A&Ox3, b/p 86/50, p 92, t99.0, r16 even nonlabored. No jvd. Wheeze to url on inspiration, Lungs clear LL bilaterally.Chest equal. Abdomen flat, non tender. Bowel sounds ax4q. Denies dyspnea,sob, pain, or needs at this time.Bed low position, rails up x2, call light in reach.............CB
Thank you!

First of all, you do have to do what the instructor wants, lol!! This is how I would chart the above

0730-AM assessment complete. Pt A&O x3, VS:86/50-99.0-92-16. Resp equal, even and nonlabored, inspiratory wheezes noted RUL. All other lung fields clear. Abd flat, nontender, BS's + x4. Pt denies pain, sob; resting in bed with eyes open, semi-fowler's position. ....................................XXX

I don't usually chart about bed rails and such does anyone else? Also, what's this pt's dx? Those vitals aren't so great.

tvccrn, ASN, RN · Oct 27, 2005

I don't usually chart about bed rails and such does anyone else?

I would just to CYA. In this time of sue-happy people I think it makes sense to chart things such as this.

crb613, BSN, RN · Oct 28, 2005

First of all, you do have to do what the instructor wants, lol!! This is how I would chart the above
0730-AM assessment complete. Pt A&O x3, VS:86/50-99.0-92-16. Resp equal, even and nonlabored, inspiratory wheezes noted RUL. All other lung fields clear. Abd flat, nontender, BS's + x4. Pt denies pain, sob; resting in bed with eyes open, semi-fowler's position. ....................................XXX
I don't usually chart about bed rails and such does anyone else? Also, what's this pt's dx? Those vitals aren't so great.

Thanks & the dx cancer.

My CI says no to bedrails/call light also. No to vitals, BS's, Abd flat/non tender. Also don't say pt. its their chart......Instead The lung wheeze ok & denies pain,sob,any needs. Will monitor...................................xx

I am just confused because I thought if you do not chart it you did not do it??? This is what I have been taught up to now. My CI says there is too much info & no one will read it cause they will not have time. So I said I would work on it & look at charting done by the nurse's at the clinical site to get a better handle on it. I was told no because they don't chart right either!:imbar

crb613, BSN, RN · Oct 28, 2005

I would just to CYA. In this time of sue-happy people I think it makes sense to chart things such as this.

Thanks & this was the reasoning behind charting this. This is what I said to my CI.......did not really get an answer except, Well yes, but it does not need to charted????????????? Ok so if the client falls out of the bed......were the rails up or down & what position was the bed left in & did she have access to the call light so she would not try to get up on her own??? I am sooo confused. :uhoh3:

truern · Oct 28, 2005

Get your CI to give you written examples of what she expects. That way you have the "proof" when she comes up with different expectations

sabrn2006 · Oct 28, 2005

Does the facility have a flow sheet to document routine care like hygiene, lung sounds, bed rails, etc? If so, then putting it in the narrative would be double documenting. It does seem like this info should be available somewhere. I know that when writing notes at our hospital I would put something generic like "able to make needs known. will continue to monitor" along with the more specific info to that pt.

Thanks & this was the reasoning behind charting this. This is what I said to my CI.......did not really get an answer except, Well yes, but it does not need to charted????????????? Ok so if the client falls out of the bed......were the rails up or down & what position was the bed left in & did she have access to the call light so she would not try to get up on her own??? I am sooo confused.

SouthernLPN2RN, MSN, RN, APRN, NP · Oct 28, 2005

In real life, I always charted on a flowsheet. My actual note would look like this:

0730-AM assessment complete, see flowsheet for details. Wheezes noted RUL, denies SOB, cont. to monitor. .............................................XXXX

Or something to that effect, lol! I did put in there to "see flowsheet" just in case the papers ever got separated. That way the reader knew it had been documented elsewhere.

crb613, BSN, RN · Oct 28, 2005

They do have a sheet hanging up that has Pt. care on it....baths, I&O's, ambulation ect the CNA's do this.They also do the vitals & have a sheet for them. Now I guess where I am confused is that what the CNA's do is documented but when the nurse is doing these things and the CNA's have already marked it on the sheet.......What do ya do? I just want it to be known that I am giving care, monitoring the pt & am leaving them in a safe enviro. doing my assessment & noting what is taking place. As a nursing student I of course do it all......& it would be documented as I am doing the CNA part as well. I hope I am making sense, just wondering if I am not documenting as a CNA but as a Nurse........How do I prove what went on. Did I mention I was confused?? :lol2: Thanks to ya'll

wengrn · Oct 28, 2005

charting is an old issue in the college of nursing... when i was a student we used to follow the so-called SOAPIE (subjective, objective, assessment, planning, intervention, evaluation... duh!) in charting... as for me i don't need to chart something that is already existing in the assessment form, waste of time... with lots of paper works on the floor (especially when you have an admit), we tend to focus on the paperworks rather than the bedside care... something that was so frustrating for me when i was following up my students in the floor...

just write what you see and do... assessment on lungs, abdomen, skin, etc - don't they appear in your assessment form? if there's any changes you see from the skin integrity on the previous day's assessment (e.g., it became worse), that's the only time you chart it... the VS? do we have to put it in the narrative report since it appears on the VS sheet already? if there's any issues about the vitals, write it... like, "BP suddenly dropped to 70/45, called the doctor, and made order..." make the narrative report (or charting) clear, concise, specific and short... :specs: that way, we have time to run when our dear patients call us and not making them wait because of the bloody paperworks kept piling up to our neck! :nono:

bjm · Oct 28, 2005

I would have charted something like this: Shift report received from J. Doe, RN. Pt received in semi fowlers position, a&o x 3, is able to voice needs ( or write needs, or shake head yes/no, etc), VS (fill in #'s), with resp even and nonlabored, denies SOB. S1, S2 auscultated, no murmurs noted, pulses x4 +2, cap refill

bjm · Oct 28, 2005

Oh yea, I forgot to put in my previous note, when you start your note, Pt received semi fowlers, I forgot to also say, with rails x2 and bed in low position, pt able to voice needs........It is important to address those bed rails and position of bed. If pt falls, the first question that will arise is, was the bed in low position, what rails were in place, what fall percautions were in place. Sorry, see, we all forget an item or two when we are charting.