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Discussion

Need help with documentation

Hello everyone!

I just recently graduated and started working as an RN in a medical acute floor last July 4th. It is already been a month and still I do not feel confident that I am documenting everything as I am suppose to. I always ask my preceptor to review my charting and documentation every now and then to see if I am doing it right or if there is anything missing and she said I am doing fine. But I still do not feel confident and I cannot understand why.I need your help what makes you confident you documented everything.

We do an hourly rounding, do you thing I should document it on the progress notes everything I observed even it was the same as the last hour? My preceptor do not think so, I need another opinion on this too please.

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From my own experience working on a CPOE and totally computerized charting arena, I don't see anything wrong with charting "no changes from previous assessment noted" on your hourly rounding flowsheet.

That would ensure that you have documented that you 1) did in fact round on that person hourly, and 2) that you observed no changes.

Of course, you should also do what is required for a full assessment at lesat as often as you are mandated to do per the p/p of the floor you work on. Example: I have to chart full assessments including cardiac strip info q4 hours. But in my "focus note" at the end of the assessment if nothing has changed from the first assessment of the day at 0800, when I do my 1200 assessment, I complete the entire assessment again, but my focus note might only say the above quote about no changes noted.

Make sense? ;)

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