Need help with proper documentation

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Hi guys,

This is probably going to seem stupid. I seem to have an easy time doing the actual skills, but when it comes down to writing things down, I am not doing so well. We have a nursing database that we are using during our PA labs, and I do fine writing subjective information, but during the objective information we aren't supposed to use words like "normal".

When I'm documenting objective information like S1 and S2 sounds, how do I document that? I can't say they sound normal..and my brain just won't wrap around the best way to write it, and I'm incredibly anal about this stuff! I hate having scribbles when I am trying to make this look good for when it's evaluated!! Help!!! :bluecry1:

If you need more clarification, please let me know. I am half brain-dead as of now and I may not be communicating what I mean very well. :confused:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Well, what is a normal S1 and S2? That's what you chart. "S1 and S2 present, rate 60, rhythm regular." There's not a whole lot to say about what is actually "normal". Sometimes it's easier to say "S1 and S2 present, no S3 or S4 noted".

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Thanks! I know I seem stupid asking something so simple, but I'm also taking Pharm and Phys along with this first semester nursing course, so I'm frazzled, and while they talked about documentation in class, we weren't given a whole lot of examples as to what was expected of us, and so I'm all flustered and worried that I'm doing it wrong. I tend to be the "freak out" and realize I'm making it harder than it is type of person when I'm doing something new. :imbar

I probably just need to calm down. :uhoh21:

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