New ER RN grad...need documentation help!!

[inteRN]

Hello!! Does anyone know somewhere I can go online and see a sample(s) of how to document on a T-sheet? I always feel like Im either writing too much or not enough. The doctors probably think Im a retard when they read my assessment documentation...its a mess. Did I write too much? Did it make sense? Did I cover my ass enough??

Any tips?? My preceptor is helpful, but I can't keep asking her whats the best way to chart this and that?? Its so frustrating and time consuming esp when your new and dont know what you're doing anyway...

Thank you!!

[bill4745, RN]

Try to read what the nurse caring for the patient before you wrote. After a while you should learn what the norm is.

[SlightlyMental_RN]

I like this book:

http://www.amazon.com/gp/product/1582559872/ref=ox_ya_oh_product

[ImMrBill3, RN]

You do documentation in your ER? Just kidding but when we get patients up in S/M ICU the documentation is pretty bare bones and very much acute condition focused. I agree with the previous poster to read others notes and learn from the example. I also applaud any nurse who works to get good assessments and history you might consider putting the "extra" information at the end of the note and using that crazy documentation shorthand...