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Nurses   (2,967 Views 7 Comments)
by jmolinaRN jmolinaRN (Member)

jmolinaRN has 4 years experience and works as a Staff Nurse.

3,385 Visitors; 96 Posts

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Hi folks,

I'm a little ashamed to open this topic but I really need help.

As a student and when I began my practice as a nurse, we usually do traditional charting which is sort of a narrative charting which describes what we did for the patient.

Recently though we have adopted the FDAR method and whilst it's favorable and good, I'm running out of ideas on what to write in my patient's chart. I am aware that health teachings maybe used as part of FDAR however, given that the patient had been staying too long in the hospital (11 days) just to complete an antibiotic therapy that started on day 5, I'm running out of focus and my charting for most patient appears like a ditto from the earlier shifts (we have 3 shifts a day).

I must admit my time management skills aren't very polished given that the n:p ratio has bulged because of the outbreak of Dengue Haemorrhagic Fever. I tried to look into the labs but honestly, I am finding it difficult to justify the needs of some patient to be remaining in the hospital. I tried instituting bleeding precautions because of the low platelet count but I still find myself at a loss the next day when I handle the same patient with a higher but still below normal platelet count.

Any suggestions?

Thanks,

- Josh :idea:

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7,138 Visitors; 460 Posts

School -vs- reality

Do precisely what it is you are told to do by your instructors. If they want you to over-analyze everything, then do it.

However, here's a little side homework for you.

Take a close look at what the experienced floor nurses are charting. Remove all of the redundant nonsense that is already charted elsewhere, and you are left with the basics of what should be charted in narrative.

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Hospice Nurse LPN has 15 years experience and works as a BSN student/hospice nurse.

16,473 Visitors; 1,472 Posts

jmolina23--I'm having the exact opposite problem--trying to transition from nurse to student. I have to stop and think, "ok. it's work so chart short and sweet (our NN are basically a check off with a narrative for anything out of the ordinary)" or "it's school so write a novel about the pt". You'll get the hang of it soon.

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roser13 has 17 years experience and works as a RN.

50,565 Visitors; 6,504 Posts

"Do precisely what it is you are told to do by your instructors. If they want you to over-analyze everything, then do it."

I don't believe that OP is a student...she has already started practicing as a nurse.

OP, I am not familiar with the FDAR....what type of charting is it?

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7,138 Visitors; 460 Posts

"Do precisely what it is you are told to do by your instructors. If they want you to over-analyze everything, then do it."

I don't believe that OP is a student...she has already started practicing as a nurse.

OP, I am not familiar with the FDAR....what type of charting is it?

My mistake, my apologies to the OP.

Then now is the time to sift through and eliminate redundancy in your charting. This and prioritizing interventions, is the KEY to time management.

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classicdame works as a Hospital Education Coordinator and adjunct nursing.

2 Articles; 26,024 Visitors; 7,255 Posts

look at the physician's notes. They have to justify the patient's existance too.

Ask the case manager. They are usually the ones doing utilization review and can tell you the rationales.

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jmolinaRN has 4 years experience and works as a Staff Nurse.

3,385 Visitors; 96 Posts

OK Thanks guys, I'll try to polish up my charting and work my way until I remove the redundancies.

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