Need help with charting?

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This might be a dumb question but I'm having difficulty charting even though it's suppose to be fairly easy. I'm mainly confused because we haven't been given any guidelines or anything to guide our charting, we do practice in school and our instructors go over them but they always have something negative to say (or correct) so it seems like theres no right way of charting? They all have their own way of doing it which confuses me. Should I just stick to SOAP?

Is there a clear cut way of charting? Or even a book? Just confused.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

As far as resources for charting are concerned, there's a book called Charting Made Incredibly Easy and another one called Surefire Documentation.

I found find out which way your instructors want you to document and go from there.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

http://www.cno.org/Global/docs/prac/41001_documentation.pdf

Nursing Center - CE Article

VickyRN Asst. Admin Hand-off is the provision of verbal and/ or written

information from one primary health care provider to another so that pertinent care, treatment, or service needs as well as the patient’s current condition and

any recent or anticipated changes are accurately communicated.

SBAR is an acronym for situation, background, assessment, and recommendation.

Situation: Identify the patient and who is involved. Identify the problem/diagnosis, recent changes.

Background: Review of systems, pertinent medical history (allergies, code status, chronic diseases, and disability), safety/ cultural issues, precautions, labs, medications, mobility status, mental status, next of kin, equipment, tubes, drains, medications, IVs

Assessment: Plan of care, summary of current condition, catheters, drains, lines, tubes, treatments.

Recommendations: Pending tests, suggestions or requests, physicians’ orders, what is to happen, where, when, and how, to-do items, anticipated changes, and outstanding issues.

paperclip.png Attached Files

Assessment, Nursing Process, Charting
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One of the very best compliments I ever rec'd from a physician was that he loved my documentation because he could really see what the patient looked like by reading it (bless you, John Mehigan, vascular surgeon, wherever you are). That is what you are aiming for.

The best way to think about nursing documentation is to think first about what medical records are used for. Quick! How many things can you think of?

1) Communications between staffers and disciplines

2) Legal documentation of events, assessment, and care

3) Supporting billing and insurance reimbursement (and that becomes your paycheck)

4) Clinical research

5) Education

6) Quality improvement/risk management

Gold star if you can think of some more!

The point is that you have to keep a lot more in mind when you write your notes and document your meds. All of those folks will be reading them sometime and counting on you to be accurate and descriptive. If your nursing documentation class had that in mind, by all means, take it to heart and use it every day. If it didn't, consider a creative writing class that teaches you how to see beyond the obvious and how to use good English to describe it for the reader. I can tell you at least one excellent doc, a lot of bean counters, medical and nursing researchers and academics, and many lawyers and nurse legal consultants will appreciate that.

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Thanks for the responses!

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