Nursing Documentation

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Hello all,

I am doing a research project on the subject of "How should students learn to document care while in nursing school"

First for all students does your program provide a comprehensive class on documentation, and the legalities, or is this a topic touched on by a few instructors requiring proficiency for clinical experience?

Secondly for those who are already nurses, how do you feel about the quality of documentation from new grads, and did you have specific training prior to entering the field?

Thanks in advance for any help on this topic. Web links with information about documentation and nursing errors is also helpful :) if anyone has some.

Csuev

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My training consisted of instructors looking over what I had written then suggesting changes. When I audit charts in my current position the new grads seem to do better than the older nurses because they are trying to put in a lot of words when the older nurses barely jot down a complete thought. I tell new grads to focus on the diagnosis first. The chart should not have 12 hours of space in it. We expect that the patient said or did something during that 12 hours. Pneumonia? What were his sats while eating? after a trip to bathroom? Was O2 level changed and why? The chart ought to indicate the nurse is aware of why the patient is there and what is being done to expedite discharge. IMHO

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Specializes in med/surg, telemetry, IV therapy, mgmt.

my introduction to documentation as a student 30 years ago was to write my charting on a piece of paper and show it to my clinical instructor first. if she approved it, then i could write it in the chart. otherwise, i had to make any corrections to it first. it's been 32 years since i've been in nursing school, but i clearly remember being told over and over, just chart the facts and never your opinions. put quotation marks around anything significant the patient tells you. so, when soap charting came out, i had trouble with the assessment part of it. these days with the check off sheets i keep my narrative charting confined to things that expand on some category in the checkoff section that i can explain further. i also chart patients trips to x-ray or pt and visits by specific doctors if i notice it. i also make sure that i address what is going on with the patient with relation to their medical diagnosis. if they are in for pneumonia and i will generally chart with respect to nursing interventions being done that match those that are (or should be) in the nursing care plan.

http://www-isu.indstate.edu/mary/chart.htm - this is a sample of how to do a narrative charting of a head to toe assessment. it is for a patient with a recent cva.

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I learned the same way that Daytonite learned. I am now an RN-BSN after 13 years of being an LPN. In my LPN-BSN program, we did not have a specific charting class.

We have new grads..LPN and RN's. I am a preceptor in my facility and I teach a documentation class. We had to implement this as the new grad's LPN and RN alike, lack charting skills.. Some of the charting was insane.

I stress giving the clinical picture.

In new nurses I feel that their charting skills will improve in time. It is the seasoned nurses who concern me.... They don't chart enough. I don't know if it is a time issue or what, but it is concerning.

Flow sheet charting has been a blessing and a curse. When I started nursing, Narrative charting was the rule of thumb... PIE, SOAP, charting by exception..... Now flow sheets...I prefer Narrative charting.

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Thanks for the info, I am in a BSN program and find I am fustrated when they ask me to document something yet I have only had a small amount of exposure and no formal training. Considering this is a major issue relating to nurses being investigated and losing their license it would seem the focus on this issue would be elevated.

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Specializes in Emergency, Trauma.

Whenever you have the time, glance over experienced nurses' notes; everyone has a different style and it helps to see how others make their notes "flow".

As far as CYA charting, as a cardinal rule, if you are charting an abnormal assessment finding ALWAYS then document what steps you took to correct the problem; whether that be calling the doc, giving a med, reassessing, applying O2, repositioning, whatever. I can't stand it when I see that the nurse before me has charted a sky high BP or a c/o pain and then there's no indication that she did anything about it.

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Whenever you have the time, glance over experienced nurses' notes; everyone has a different style and it helps to see how others make their notes "flow".

As far as CYA charting, as a cardinal rule, if you are charting an abnormal assessment finding ALWAYS then document what steps you took to correct the problem; whether that be calling the doc, giving a med, reassessing, applying O2, repositioning, whatever. I can't stand it when I see that the nurse before me has charted a sky high BP or a c/o pain and then there's no indication that she did anything about it.

im looking for how to say it, not what to say. i can write a book, but it does not look right.

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im looking for how to say it, not what to say. i can write a book, but it does not look right.

AHA! Finally someone else who has/understands my dilemma. I'm going thru this exact same thing right now. I know *what* to chart, I just don't know HOW and no one teaches us. You just fumble through. Like the other poster said - for something as legally important as charting, I'm shocked there isn't more training in this area.

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I'm with you. There should be a documentation class required in the nursing programs

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Specializes in Maternal/Child, Med/Surg, Psych.

I have had pts who have an initial assessment charted and nothing else for the full 12 hours:eek:. I tend to chart everything and it has saved my butt many times. When in doubt write it out...but KISS--keep it simple stupid, don't try to use all your big words at once and be objective-no personal :twocents:..Check off can be good if used with a little common sense but I am finding that newer nurses are not taught that check-offs don't cover everything and sometimes a short blurb can save you in the long run. 1-2 yrs down the line you may need a reminder of what happened during your shift, I can barely remember last week much less 1-2 yrs ago but it will happen you will get that call not because you did anything wrong but because people in hospitals are sick and sometimes the outcome is not good. With a short note you can say without a doubt what happened and what you did.

As for format I just give general narrative notes --when doing drsg changes I document wound appearance, drng etc..along with a list of supplies used so the next nurse will know what will be needed and have an idea what is under the drsg (if they read my notes.)

Good luck and glad to hear you thinking about it ahead of time--shows you are concencious and will do a good job.

:saint::saint::saint:

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Specializes in long-term-care, LTAC, PCU.

We had a formal class on documentation (about 8 hrs. of lecture). The only problem is that everything at the facilities I go to for clinicals is done on the computer, and is pretty much chart-by-exception. Most clinical instructors also made us write a huge head-to-toe note.

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Im a new Grad LPN 7/08...We didn'thave a documentation class... and Im learning as I go...The nurses that have Oriented me says it will come in time, to just make sure I document what has happenedand to write things down throughout my shift...It is very hard to learn. But I know in time it will get easier. At the Facility I work at it is chart by exception. Pt in a receive note and your general assessment and then anything that happens w/ that pt throughout your shift. It's getting better...Wish me luck...

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