Need help with nurses notes

I have always charted gross observations followed by head to toe as my first assessment each shift.

Then, for subsequesnt entries throughout the shift I stick to gross observation, followed by involved systems (head to toe order) followed by specifics of a tx or activity unless said specifics came into play with the systems entry.

Pertinent equipment that doesn't fall into the entry elsewhere brings up the end.

Just remember, always think 1)what is obvious when I walked in and 2) start at the top and work down. Doing this will help you always get everything in accurately.

Also, contact your Education Dept. or Risk Management. They may have examples to share.

What type of charting does this hospital use?

Where I work, we use PIE charting. It was hard to get used to at first, but now I find it a breeze to use.

What type of charting does this hospital use?

Where I work, we use PIE charting. It was hard to get used to at first, but now I find it a breeze to use.

debbie,

What is PIE Charting? I know about SOAP but never heard of PIE.

We chart on the computer where I work. Almost everything is listed. You simply add a check in the box beside what's going on in every system of that patient. Helps ya not to forget to chart something. If there's anything you'd like to add, there's a comment box to type that in. I love it!

We used "SOAPIE" notes.

Subjective

Objective

Assessment

Plan

Intervention

Evaluation

Sometimes the best training I got on how to do something was watching someone who knew what they were doing, and doing what they did. Read the notes of nurses you respect... ask your new nurse manager for some help. I like the idea of the education and risk management department of the hospital as a resource too.

And thanks for that URL. I'm always looking for ways to hone my skills.... It downloads using Acrobat Reader. I noticed a reference to the book Charting Made Incredibly Easy as well.