Narrative Charting Help Please

Race Mom, ASN, RN · Jun 1, 2007

Here is the example right from the "Charting: Made Incredibly Easy" book...

05/31/07...2245...Pt 4 hours postoperative: awakens easily: oriented X3 but groggy. Incision site in front of L ear extending down and around ear and into neck-approximately 6" in length - without dressing. No swelling or bleeding, bluish discoloration below L ear noted, sutures intact. Jackson Pratt drain in L neck below ear with 20 mL bloody drainage measured. Drain remains secured in place with suture and anchored to L anterior chest wall with tape. Pt denied pain but stated she felt nauseated and promptly vomited 100 mL of clear fluid. Pt attempted to get OOB to ambulate to bathroom with assistance but felt dizzy upon standing. Assisted to lie down in bed. Voided 200 mL clear, yellow urine in bedpan. Pt encouraged to deep-breathe and cough QH and turn frequently in bed. Antiembolism pads applied to both lower extremeties. Explanations given re: these preventive measures. Pt verbalized understanding.---------------Joe Schmoe, RN

05/31/07...2255...Pt continues to feel nauseated. Compazine 10mg I.M. given in R gluteus maximus.----------------------------------------------Joe Schmoe, RN

05/31/07...2335...Pt states she is no longer nauseated, remains pain free. No further vomiting. Pt demonstrated taking deep breaths and coughing effectively.------------------------------------------------------------------Joe Schmoe, RN

Sorry for any typos

sports2245 · Jun 1, 2007

I have heard a lot of people mention "Charting Made Incredibly Easy". Do you really like the book? I probably should go out & buy it.

Race Mom, ASN, RN · Jun 1, 2007

I rarely use it and it doesn't always help. I like most of their other books, but this one is just plain boring. I got much better help her on Allnurses. If you want to buy any of these books, buy them off Ebay. I got this one in a "lot" of 3 books for the price of one new one.

Narrative charting is like writing a book in a timeline fashion.

Psqrd · Jun 1, 2007

This is on a card that I carry in my pocket every day...and so do my classmates!

1. Oriented X4

2. Pain level on 0/10

3. Significant Pt. "statements"

4. Appearance & location of dressing

5. Description of wound

6. N/G residual/placement/feeding

7. Foley--description of urine

8. CPM, SCD, O2 cannula @ 2liters (example)

9. Pt. Activity---turn Q2H, Ambulate to...up in chair, HOB elevated to?

10. D/C IV

11. D/C Foley

12. Any abnormals and RN notified

13. Enema, catheterization, wound irrigation, etc

14. Any other unusual observations

Never had a complaint about my charting...I hope this helps.

P2

Daytonite, BSN, RN · Jun 1, 2007

http://www-isu.indstate.edu/mary/chart.htm - this is a sample of how to do a narrative charting of a head to toe assessment. it is for a patient with a recent cva.

http://medi-smart.com/documentation.htm - do's and don'ts of nursing documentation

https://allnurses.com/forums/f205/examples-charting-138835.html - weblinks to examples of charting for students

http://www.nursingcenter.com/prodev/ce_article.asp?tid=622257 - ladies & gentleman of the jury, i present. . .the nursing documentation. a ce article from nursing 2006 on advice when charting patient care that may help you sidestep a lawsuit or be well prepared to defend yourself in court if you have to.

https://nursing.advanceweb.com/common/ce/content.aspx?courseid=251&creditid=1&cc=36532&sid=1095 - documentation: avoid the pitfalls of improper documentation practices. an article from advance for nurses

kayel · Jun 1, 2007

Those are some excellent resources, Daytonite! I am going to look those through this summer .. it's hard to remember exactly what they said in our labs and I thought it wasn't explained very thoroughly (or at least thoroughly enough for me lol) .. it always seems like we see such bad examples of charting on the floors and I'm looking for some good ones so I'm not just another bad example. Awesome!