need charting examples

RN0707 · Nov 10, 2007

I am a new nurse(3months) But I also have a child that has had home care nursing since he was 2 or 3! I think it sounds good some may say too detailed I say it really gives a clear pic of what went on. When mom reads it she is able to see how the day went. and if something goes wrong at some point she is able to take the past notes with her to the doc and possibly find a sign or a reason from your deatlted notes. that is a huge help and can save a family alot of heart ache and time trying to figure out what is wrong with their child!

in a hurry

I will try to send an example later

Perpetual Student · Nov 10, 2007

"Client cont with Passy Murri cap, excessive drooling, productive cough, client pushs same out of mouth. oral sx for same."

I would be a bit more descriptive re: the product of the cough (color, consistency, and so forth).

You might not need to be so specific re: routine meds depending upon the nature of your MAR and your agency's policies. I generally just write "All scheduled meds given per plan of care" (abbreviated quite a bite) as the dilution and flush is laid out on the MAR.

Giving a time for how long the brace was on might be helpful to someone reading it, unless it's on a flow sheet somewhere else.

My agency requires us to organize our notes based upon systems and include our assessment findings in the notes. A sample might look something like this (well, hopefully some of the assessment findings are different, lol):

Rec'd report from eve nurse and assumed care. [Resp] Trach patent. Suctioned for moderate amt thin, clear secr. Lungs CTA. Breathing easily. Occ stoma suctioning for sm amts thick whitish secr. [CV] PPP. HRR. Skin W/D. No edema. BP 300/20. C/o "unbearable chest pain." [Neuro] A/O x3. C/o HA "7"/10. Declined PRN Tylenol. [GU] Straight cath'd for 3000 ml of cloudy, purple urine w/ kool-aid odor. Lg amt frothy green disch from urethra. [integ] Trach care performed. Stoma is clean, intact and w/o s/s of infection. [Misc] Clt swung by tail for repositioning. Report summarizing above given to peeping Tom through window.

Sorry, I worked last night and am in somewhat of an odd mood in addition to being exhausted. In all seriousness, look at what some of your colleagues have written for the cases that you work. Remember to focus on important things rather that fluff. One of my pts has a funny story about a nurse that used to work for him documenting that his dog was misbehaving. :lol2: When I was starting out the documentation was the hardest part for me, but now it's fairly easy. Once you develop a mental template it is easy to input the specific details for the shift. If there's something ABNORMAL for the pt be sure to give plenty of detail. Always follow up on the effectiveness of any PRNs given.

Good luck and I hope the foregoing was at least somewhat helpful. I hope you enjoy your job as much as I do mine.

caliotter3 · Nov 10, 2007

Your example and the others given are good. At my agencies, I was also required to state at the beginning of my narrative summary that I did an assessment and took vital signs. Also, at the end of the shift, we were required to state the general condition of the patient, and who we reported off to, and left the patient in care of. HTH.