Nursing documentation. Newer nurse needs help

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Specializes in geriatrics, geripsych.

Hello to all. I am a newer nurse. :clown:

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Specializes in Pediatrics, Geriatrics, LTC.

Try The "Incredibly Easy" series. There's one on charting. Didn't you practice in school? I know we had to chart every day during clinicals.

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Specializes in ED, ICU, PSYCH, PP, CEN.

Chart what you observe, what the pt tells you and what you do to the patient, who you talk to about the pt.

For example you walk into the room and the pt has fallen: chart, pt found on floor at 0800, examined and found to have painful right knee, assisted back to bed by this rn and rn Betty, Dr Joe notified, order to get xray and give tyhlenol rec'd.

or pt bathed and dressed without difficulty, pt has trouble working with buttons, pt ambulated to restroom with minimal assist.

Don't try to use fancy terms or medical words, just chart what you do and at what time, also chart pt response to things such as headache decreased after tylenol, or pt lungs sound clearer after neb treatment.

I used to try to sound all professional and use big words but now I just chart using simple words. I try to chart almost everything I do so that people know what I did with my day.

I must be doing something right because they always say my charting is great.

If you have any more questions feel free to private message me

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Specializes in ED, ICU, PSYCH, PP, CEN.

There are books on charting and also CE seminars etc. I have taken these classes and read a few of the books. It helped alot. I also chart who is with the pt and when if I get the chance. Additionally, try to never save your charting till the end of shift. Do a little and then chart a little, then do some more. Charting is very important and always remember, if it isn't charted then the law says it wasn't done

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