Documentation! How do you document your progress notes???

[RN28MD]

I have started working in a medical floor and having a hard time documenting. I try to write what happened on my entire shift but can't seem to word thing right. I even bought a book on charting from the incredibily easy collection ) but is not enough info. Plz any suggestions would be great!

I have to write on safety for everyone and teaching but how do I word this with out writing a book????

[corky1272RN]

You don't have to write every word to have it make sense. Instead almost do bullet points of the pertinent info.

Ex 1: I went in to the pts room, I went to the drawer, opened it, noticed her clothes were folded properly. The pt was lying in bed, I called her name and she said "Hi", I asked her if she needed anything, she said no. Then I smiled and left the room.

Ex 2: Pt in room, lying in bed, responds to verbal stimuli, no voiced c/o at this time.

Ex 1 was too much, Ex 2 said the important stuff. Also use make sure to use abbreviations that help lessen the amt you have to write, such as: c/o (complaints of), HA (headache) etc.

Oh, don't leave all charting to the end of the night as well, if something happened to one of your pts then the MD (or other hospital personell) may want to see the charting or you could forget some important info.

[RN28MD]

Great point! Thanks for replying.

[cardiacRN2006, ADN, RN]

Chart the important things as they happen. Never at the end of the shift. And if it's impossible to chart during the shift (like a code situation or a good septic shock) then I chart the biggies on another piece of paper.