Need Documentation Tool

[sweetnurse08]

I am a new LPN, and in desperate need of help. After i assess a pt even if i take quick notes it doesnt end up making it to my assessment. I would like to have some kind of paper assessment to do on each pt then transfer this to my computer documentation, so i know my charting will be accurate. I have searched google untill im blue in the face:crying2: and cant find anything relevant. Can you help I didnt know where else to look.

[VickyRN, MSN, DNP, RN]

Moved to the LPN Forum for better exposure.

[NurseCubanitaRN2b, BSN, RN]

If you do it by system you should be fine. You're speaking in regards of head to toe correct? I do have something that I used while in nursing school and i passed it on to others. It was a little cheat sheet but I don't have it in computer form. I will do some searching and should have something within the next day or two, I know I have it somewhere.

[NurseBlueBear]

I posted a link for you for something called RN Report Card. It works for RNs or LPNs. It gives you someplace to write down all of your information. I have heard great things about it. Hope this helps you out.

http://www.rnreportcard.com/index.php

[TheCommuter, BSN, RN]

Here's a basic documentation tool that is easy for me to remember. . .

It is called DAO (Data - Action - Outcome).

"D" is for documenting the objective and subjective data: 98.6, 74, 18, 120/80. Skin warm & dry to touch, dressing CDI, alert & cooperative during exam, no s/s of acute distress noted, pt. states, "I have a headache."

"A" is for documenting the actions or interventions you took: Administered Tylenol 500mg, 2 caplets by mouth per order. Offered oral fluids for hydration. Taught pt. to report any pain or discomfort in a prompt manner to nursing staff.

"O" is for documenting the outcome or result: 60 minutes elapsed and pt. reports pain level of zero using numeric scale. Pt. states, "My headache is gone." Pt. observed accepting sips or water and watching television.