Nursing documentation help

Posted
by tsm007 tsm007 Member Nurse

Has 2 years experience.

I did next to no narrative charting in school and am dying here trying to do it now. I am working in LTC/Skilled Nursing Home. My charting is pathetic and I want to fix it. I need some good references. I learn best by doing and am struggling with references. They tell you WHAT to chart on, but not HOW TO WORD it. I get a list of things I should be charting about, but get really frustrated with wording.

For example, fall charting. Not sure how you word this. If they didn't fall on my shift, but I need to chart follow up. Not sure if I should mention the fall, especially unwitnessed falls. I mean the nurse before charts "resident found on floor". So what do I chart for post falls? I got I need to post vitals and neuro checks, but how do I word it? "Resident neuro checks WNL from being found on floor" I mean that makes no sense? UGH. I wish I had a book of examples.

I feel like EVERY single thing I go to chart I need an example if it's something I've never charted on. I'm not stupid. I swear.

Discharge charting and admission charting I have not done at all and I do not think I could at this point because I do not know what needs to be included, how detailed I need to be and WHAT details to include. I have searched high and low and am not finding good references with examples. I bought one charting book and found most of it not that helpful for LTC and generalized assessments.

Do's and Don'ts

I can't go back and unchart my bad charting, but I want to start charting things the right way. I need some more do's and don'ts too. For example, I just read recently that you shouldn't chart patient sleeping, but instead patient resting with eye's closed.

I'm just really frustrated and I know most nurses seem to not want to "spoon feed" this to me and yes, I guess that's what I'm asking for. Any help would be appreciated. I would love to take a course just on documentation. This is just not so intuitive to me.

vintagemother

vintagemother, BSN, CNA, LVN, RN

Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,. 2,714 Posts

If I was charting on a prior fall or injury or other problem, I'd first consider the "why" of the charting. The "why" is likely to show a pattern of the pt recovering, or getting better, or hopefully not, worsening.

Thus, I'd include who what where when why and how and include relevant sbar info as it applies.

So if my pt had fallen with no apparent injury, I'd assess him myself. Ask what happened, is he in pain, I'd look at the injured area.

Id write "s/p fall on 9/26/2015, @1400 this nurse assessed the L hip. No discoloration or damage to skin integrity present. Pt denies pain, stating, "I fell right here on my left hip, it doesn't hurt, I'm fine." Pt teaching provided to pt on importance of (whatever factors led to the fall, such as using assistive devices) Writer asked pt to notify nsg staff if any pain develops. Pt observed walking in the common areas of the facility with a steady gait. "

Notes on sleeping pts are different. I wouldn't wake them to assess unless required by facility that I do assess the site qshift. Pt observed laying in own bed in own room with eyes closed at 0002 and 0600. I also used to refer to the techs notes to add info such as "pt ate 90% of their B, L and Dinner. No PRNs requested during this shift.

I used cheat sheets for my narrative charting. Like a skeleton I could fill in with pt specific info. I looked at other nurses charting that I liked and used skeletons that would allow me to incorporate similar items..

CaringGerinurse525

CaringGerinurse525

Has 2 years experience. 117 Posts

Resident continues on post-fall assessment without incident. Denies pain/discomfort at this time. No new areas of bruising noted. VSS. Neuro-checks Wnl. Will continue to observe.

Short and sweet is the key. Give enough information to show you are assessing the patient.

tsm007

tsm007

Has 2 years experience. 675 Posts

If I was charting on a prior fall or injury or other problem, I'd first consider the "why" of the charting. The "why" is likely to show a pattern of the pt recovering, or getting better, or hopefully not, worsening.

Thus, I'd include who what where when why and how and include relevant sbar info as it applies.

So if my pt had fallen with no apparent injury, I'd assess him myself. Ask what happened, is he in pain, I'd look at the injured area.

Id write "s/p fall on 9/26/2015, @1400 this nurse assessed the L hip. No discoloration or damage to skin integrity present. Pt denies pain, stating, "I fell right here on my left hip, it doesn't hurt, I'm fine." Pt teaching provided to pt on importance of (whatever factors led to the fall, such as using assistive devices) Writer asked pt to notify nsg staff if any pain develops. Pt observed walking in the common areas of the facility with a steady gait. "

Notes on sleeping pts are different. I wouldn't wake them to assess unless required by facility that I do assess the site qshift. Pt observed laying in own bed in own room with eyes closed at 0002 and 0600. I also used to refer to the techs notes to add info such as "pt ate 90% of their B, L and Dinner. No PRNs requested during this shift.

I used cheat sheets for my narrative charting. Like a skeleton I could fill in with pt specific info. I looked at other nurses charting that I liked and used skeletons that would allow me to incorporate similar items..

I am trying to develop a cheat sheet. I kind of have started a collection of stuff and whenever I see something worded in a way I like I add it to my list of ideas. Eventually I hope to not reference it, but do it all off the top of my head. I thought I was doing okay until I went to a different facility with higher acuity and saw how much more detail the nurses there included. I am trying to get a list going of all the details I should include. Your ideas were very helpful!

tsm007

tsm007

Has 2 years experience. 675 Posts

Resident continues on post-fall assessment without incident. Denies pain/discomfort at this time. No new areas of bruising noted. VSS. Neuro-checks Wnl. Will continue to observe.

Short and sweet is the key. Give enough information to show you are assessing the patient.

Thank you very much. Adding this to my idea bank. Once I start figuring out how to word/chart one thing I find the next thing it goes much smoother.

CelticGoddess, BSN, RN

Specializes in Palliative, Onc, Med-Surg, Home Hospice. Has 6 years experience. 896 Posts

I don't have to do a lot of narrative charting anymore (thank goodness) but I do have to do a lot of admissions charting. Typically I address when and where the patient came from "Pt arrived on unit from ED @ whatever time". I also address reason for admission "C/o whatever is complaint" and if the patient is alert and oriented, ambulatory and I also address pain. It keep it short and to the point.

I work nights so I don't do discharge. Again, thank goodness!

When I worked LTC, I would look over the previous shifts charting and go from there. It gave me an idea of what to write, and I would just use my own words.

Annie Wilkes RN

Annie Wilkes RN

Has 19 years experience. 54 Posts

"Discharge instructions reviewed with patient and spouse; both verbalize understanding. Discharged at 1800 with spouse via private car, belongings sent, scripts sent, condition stable."

tsm007

tsm007

Has 2 years experience. 675 Posts

"Discharge instructions reviewed with patient and spouse; both verbalize understanding. Discharged at 1800 with spouse via private car, belongings sent, scripts sent, condition stable."

Thank you. I appreciate all the help I get here. I am trying so hard to become a good nurse.

tsm007

tsm007

Has 2 years experience. 675 Posts

Now all I need is to get a template together for an admission note.

Alisonisayoshi, LVN

Specializes in LTC. 547 Posts

I love that this thread exists! I'm frustrated with narrative charting in LTC as well. For example, say I need chart a UTI resolving on ABO, is it appropriate to just write:

"Resident on ABO for UTI. Resident has no c/o pain at this time, no c/o frequency or urgency. Vital signs WNL. No adverse effects from ABO noted at this time. Will continue to monitor."

Am I writing too much? Too little? Yeah, we didn't really do narrative charting in school, and I feel lame.

ixchel

Specializes in critical care. 5 Articles; 4,547 Posts

Admission note for STEMI

"Patient admitted to XYU at 1947 via stretcher, escorted by ED RN. Report received at the bedside, all questions answered at that time. Initial assessment and vitals WNL. No complaints of pain or signs of distress at this time. Telemetry shows NSR with ST elevation. Room orientation given in detail, all questions answered at this time. Will continue to monitor."

Admissions, I put when and how they got to me, that report was received and how, a brief summary of assessment data with abnormals when present, focused assessment subjective and objective data (so if admitted for MI, telemetry and assessment symptoms of MI are noteworthy), and my POC ("will continue to assess" is my normal go-to).

For eventful shifts,

"Patient grabbed face of tech, with threat of "I will eat your face with fava beans and a fine glass of Chianti." Contacted MD; order received for PRN haldol. Haldol administered. Will await effectiveness and continue to assess for safety."

(Then in an addendum)

"Medication effective. Patient resting comfortably. Will continue to monitor."

On that note, it is what happened, what I assessed (if needed, like lung sounds in respiratory distress), what I did about it (contacted MD, etc), whether that worked (which may need to be done in addendum), what my plan is beyond that.

For uneventful shifts, I do a brief summary of their assessment, a line or two that is focused on progress on their admission reason, noteworthy education topics if education was a huge need for that patient (like new afib on anticoagulation), and that I'll be continuing to monitor.

Discharge: "Patient discharged to home. IV and telemetry removed, all belongings given. Discharge instructions given, reviewed in detail; all questions answered at that time. Escorted by transport via wheelchair to private vehicle. No other noteworthy events."

My notes don't usually get too lengthy at all. Sometimes they can get that way, though, if something noteworthy did occur. I actually had the longest admission note in history last week because the ED missed some really important time-sensitive things that I had to address. And of course, it was right before shift change, so everything that could go wrong, did.

For the post fall note, "Patient's post fall vitals and neuro assessments WNL. No complaints of pain or signs of distress at this time. Will continue to monitor for patient comfort and change in status."

tsm007

tsm007

Has 2 years experience. 675 Posts

I love that this thread exists! I'm frustrated with narrative charting in LTC as well. For example, say I need chart a UTI resolving on ABO, is it appropriate to just write:

"Resident on ABO for UTI. Resident has no c/o pain at this time, no c/o frequency or urgency. Vital signs WNL. No adverse effects from ABO noted at this time. Will continue to monitor."

Am I writing too much? Too little? Yeah, we didn't really do narrative charting in school, and I feel lame.

Here's what I came up with for ABT and skin tears. Hope it's helpful to you. I scoured the internet working on this. It's pathetic to have to work this hard for a narrative note, but I felt so clueless. The other posters here got me off to a good start! I need to go through the admission stuff next. That's the next big one I want to work on having a template of some sort for.

ABT note

V/S: ____________. Resident alert, verbally responsive, oriented X1-2, and able to communicate needs. No signs of acute distress. Resident resting quietly at this time with eyes closed [Or whatever resident is doing]. No signs or symptoms of pain or discomfort at this time [Or Denies pain/discomfort at this time]. Continues on PO antibiotic treatment for UTI. No adverse side effects noted. No diarrhea, N/V, rashes, or fever noted. Urine clear and yellow with no foul odor or hematuria. No complaints of dysuria. Oral fluids encouraged and accepted. Will continue to monitor. Bed in low position. Call light in reach.

And skin tears

V/S: ____________. New skin tear of unknown origin found on resident at 0200. Resident has 2 x 3 cm skin tear to left elbow. Wound is dry and free from drainage, warmth, or odor. Edges well approximated. Resident rates pain at 0. Resident states he does not remember how skin tear happened. Cleansed wound with NS, applied Curex and non-adherent dressing, wrapped in Kerlix per standing order. Will notify family this AM.

And here's my post fall narrative note

V/S: ____________. Resident continues on post-fall assessment without incident. Resident alert, verbally responsive, oriented X1-2, and able to communicate needs. Resident resting quietly at this time with eyes closed [Or whatever resident is doing]. No signs or symptoms of pain or discomfort at this time [Or Denies pain/discomfort at this time]. No new areas of bruising noted. VSS. Neuro-checks WNL. Will continue to observe. Bed in low position. Call light in reach.

and discharge note

Resident discharged to home [insert where] today. V/S: ____________. Reviewed discharge instructions with resident [and insert family member]. Reviewed all medications including drug name, purpose, doses, administration times, routes, and adverse effects. Drug information sheets and a complete reconciled medication list given to resident. Resident able to verbalize proper use of medications. Teaching provided on [insert teaching] Resident verbalized understanding [or needs further instruction on …]. Informed to notify doctor if [insert when to notify doctor]. Follow up appointment with Dr. X on 1/1/2015 at 0900. [OR Resident will make a follow-up appointment with Doctor X in 2 weeks.] Wrote doctor's phone number on written instructions. Written discharge instructions and prescriptions given to resident [OR insert family member]. Belongings sent. Discharged at 1530 via wheelchair accompanied by daughter. Transported via private car [ambulance].

I apologize in advance for cross posting the charting questions on the LTC forum. Also, I did canabalize stuff from AN too along with stuff from other sites to create my little cheat sheet.