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.