Nurse charting for clinic

[starvin4u3]

Hi Im a new grad LVN that just hired in a OB/GYN clinic. Im responsible for notifing adnormal labs to patients and calling over RX. When it comes to charting what I did .. Im a little confused on how to chart it? Please see below on how my preceptor charted, I just thought that was very vague. I need some advice or example on how to chart for the clinic, which is different from the SNF/ SubAcute

" pt was informed, rx for Amoxicilin 500mg 2 tabs BID x 10 days"

[psu_213, BSN, RN]

I would state "Pt notified that prescription for Amoxicillin was called in to pt's pharmacy--Johnson's Pharmacy on 115 Main Street. Stressed to pt. the importance of taking full course of Amoxicillin. Pt. verbalized understanding and states that she will take all the Amoxicillin as prescribed."

I'm not a clinic/office nurse, but I would imagine that the details of the rx. (Amox. 500 mg, 2 tabs, etc.) would already be recorded elsewhere in the pt's chart; however, if it is not, then it could be written out in the note about speaking to the pt.

[starvin4u3]

Ok ..that sounds better . When she documented it was only charted that one time under the patient notes . I just thought her documentation was very vague. Thanks for the example it was very helpful

[RiskManager]

The RiskManager would also like to see something about the patient being notified of the lab result in addition to what PSU 213 noted above. Something like: Patient called at 1547 hours on 6/14/15 and notified of positive UTI culture.

[starvin4u3]

Thanks I am taking all the advise . Do you know if theres a website on nursing documentation When I was in clinical I did a rotation at a Public Health Department and they were very thorough with your charting , and like I said, Im in the real world of nursing and at the this private clinic were I was hired the charting was very vague.