Nursing Documentation

Nursing Students Student Assist

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Is there a website or books to help me about nursing procedures documentation? I'm having a hard time documenting the procedures that I have done.

Specializes in NICU.

Have you read Charting Made Incredibly Easy? I skimmed through it at the bookstore not too long ago and it seemed helpful. I suggest you go to your local bookstore and check it out. Here's a link for that shows the cover of the book. Hope it helps.

Buy @ amazon Charting: An Incredibly Easy! Pocket Guid

Specializes in Trauma.

Actually, thank you:) But, I figured it out and it isn't even as hard as I thought. I was just stressed out. My professor told me to carry a little notebook with me to write things down as I go and that made the world of a difference.

Thanks for the advice.

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

There is a nursing history and physical assessment form for students that you can down download from these links at this web site.

Specializes in L&D/MB/High-risk antepartum; Hospice.

One of my clinical teachers told us to get a pocket sized notebook. This way, if you are going through a pt chart and like the way something is worded you can write it down in your notebook. The next time you are doing documentation and can't think of the correct way to word something, you can pull out your notebook and see if you have something that helps you. I did this for my 1st med-surg rotation and found it to be very helpful, and it's cheaper than buying another book.

Well if it is a soap note. Then you start with what the patient states. What you observe, Your assessment, The Plan.

A narrative would you indicate the important stats from your shift. Do you have a chapter in your Fundamentals Book that gives you examples of documentation.

for example - totally fabricated

S " The pain is unbearable."

O b/p 160/95, grimacing face, HR 112,

A Pain r/t s/p op aeb grimacing and complaints of pain 9/10.

P Treat patient with 5 mg oxycodone po and reassess pain scale.

Good luck. Just takes practice

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

You chart your nurses note based exactly what you found in your assessment data in the style your instructors have told you to chart. Nothing more. Nothing less. Based on what you've written, you should have had assessments of the lung and abdomen in your charting. Whether you are to chart by exception or everything you observed, it doesn't matter. You just write up what you discovered in examination. What did you find with your lung assessment? Cough? Nature of respirations? Lung sounds? What did you find with your abdominal assessment? Any pain with palpation? Any asymmetry of the abdomen? Any abdominal distention? Bowel sounds? A liver abscess is usually going to be found on a radiology exam of some kind, not usually by a physical exam. If you are worried that you somehow failed to detect this liver abscess, put that idea out of your mind right now. You are not a doctor and that is not in your realm of practice.

Specializes in Gerontological, cardiac, med-surg, peds.

Great resource (very thorough):

practice standard: documentation from college of nurses of Ontario.

Charting made incredibly easy, you can find it also on Ebay.

There's a book: Taylor's Clinical nursing skills (i think that's the title) which gives you examples on how to document procedures since it gives you the procedures step-by-step (with rationales) and also it's recent (published 2006 me thinks) I find it's really helpful.

I made myself a checklist during clinicals that I printed off and took each day. That way I would practice writing out my notes after assessments without prompting/help. Then I got out the list and checked over what I had or hadn't included. Over the course of the year, I went from NI on charting(lots) to getting compliments on my notes. This way you get used to the flow from what you observed, but have a failsafe.

Last noc, I wrote a book on 1 of my pts who I'm pretty concerned about fvd-wise, the nurse I had taken over for wrote 2 notes, 3 lines each. (forgot to sign 1 too) and had nothing to judge my call to the doc on(change-wise) but what happened after 1900. Point being, no way to know if the things I observed were acute changes or not, as the taped report wasn't oriented to that info, and I didn't get a f/u with her.

Your charting is important, I'm glad they drilled it into me the way they did.

Happy charting! ?

BP 165/60, HR 70.

Temperature 36,5.

No pains.

Food tastes.

In a good mood.

Wants to go to home. // PetraK


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