Nursing Documentation

[jktb]

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.

[grannypatches, BSN, LPN, RN]

I am a lpn nursing student. Today at school all of us were told that if we get 2 U's on our nurses notes and care plans that despite our grades we are out of the program. I freaked out. This is second semester and its hard. We are cramming 16 weeks into ten. I am maintaing good grades but my nurses notes are the worse. Can anyone direct me to good websites showing good examples of how narrative nursing notes should be. I have searched to no avail. I am sending for the book "charting made easy" but it will not arrive for a while. I was so upset when I came home I fell across the bed exhausted and nearly in tears. I have worked so hard in school and 2 U's can end it all. I already have 1 U. Any good advice for a stressed out struggling LPN student?

[aaa rn, RN]

Hi Grannypatches...WoW, I can't believe how archiac some nursing programs are. I've worked two sites that expected narrative charting. One employer expected us nurses to use DAIR charting, The other, SOAIP charting--both have similarities.

D = DATA. What did you hear and what do you know to be true (empirical evidence garnered thru the five senses and known facts).

A = ASSESSMENT. So, as a nurse, what did you think of the above data?

I = INTERVENTION. So, what did you do about the situation?

R = RESPONSE. How did your patient respond to your intervention?

S = SUBJECTIVE: what did the patient say?

O = OBJECTIVE: What are the known facts and what is the empirical info?

A= ASSESSMENT: See Above

I = INTERVENTION; See Above

P= Plan: What is the next step?

Using the two templates, for expample, the narrative would read something like this:

Mary Smith c/o HA. States she has tried to relax but the headache is getting worse.

Mary Smith grimaces as she talks. MAR with PRN Tylenol Q 6 hrs- HA.

Mary Smith has had a HA x 2hrs, could benefit from prn Tylenol.

Provide pt with 500 mg Tylenol.

Response: Effective or Plan: F/u with Tylenol results in half hour, contact attending if no relief.

Granted, this scenario is simplistic, but I hope it helps. Good luck.

[Daytonite, BSN, RN]

grannypatches said:

Thank you for your very helpful suggestions. it will help me a lot. I have been hearing that narrative charting is not used much anymore but our program requires it. Thanks so much your help...

I know that depending on where you work many are likely to work with check off sheets and do charting by exception. These forms were developed as time saving strategies for nurses. However, if you do chart with those kinds of forms there is usually still a place for a narrative note. No matter how extensive these check off forms are, they can't include everything. There are always going to be instances of things that are going to need to be narratively written--always. Not to instill any fear in people, but i've attended a lot of legal seminars for nurses and one thing that was always stressed is to keep in the back of your mind the idea that if you ever have to sit on a witness stand what you are putting on that form, or fail to put on it, is preserved forever and tells what you observed (or didn't observe) and did (or didn't do) for that patient. A year from today you won't remember the details, but what you put in the chart will still be there to tell the story for you. Thoroughness will never do you wrong. When i worked with check off forms, as i went down the form and realized there was something i needed to expand about in one particular section, i stopped and went immediately to the narrative section and did some narrative charting before returning back to where i left off on the check off part of the form. If i ever remembered something that i had forgotten to chart i made a late entry.

[VickyRN, MSN, DNP, RN]

Here is a head-to-toe narrative charting template that I developed for my first semester rn students last semester:

2/12/2007 0800. 86 y.o. male admitted 2/1/07 for left cva. vs 37.4° c, hr 97, rr 22, bp 140/76. alert and oriented x 4; denies any pain or distress. perrla. responds appropriately to verbal stimuli; no slurring of speech. at risk for aspiration related to dysphagia; on thickened dysphagia diet. feeds self with assistance. skin acyanotic with loose turgor. mucous membranes moist and pink. negative jvd. respirations even, unlabored. breath sounds clear to auscultation throughout all lung fields. (if your patient is on o2, make sure you record the o2 rate and delivery system here, along with pulse ox readings). apical pulse regular rate and rhythm; s1, s2 noted. abdomen soft & nondistended with bowel sounds active in all 4 quadrants. pink nailbeds with capillary refill less than 2 seconds in all extremities. peripheral pulses palpable in all extremities. moves all extremities. hand grips unequal: strong on right, weak on left. left arm has limited mobility due to weakness secondary to cva. has a 20 gauge saline lock to right forearm. site is free from redness or drainage, with tegaderm dressing intact. (if your patient has an infusing iv, make sure you record the fluid and rate in your assessment). uses urinal, has occasional episodes of incontinence. urine clear yellow. no skin breakdown noted. ted hose on bilaterally. homan's sign negative bilaterally. feet cool, dry, intact, with thick toenails bilaterally. side rails up x 3, bed in low position. call bell within easy reach of right hand. instructed to call for any needs or to request assistance before attempting to get up. verbalized understanding. side rails up x 3. will continue to monitor closely.............................. s.johnson, sn

[VickyRN, MSN, DNP, RN]

Another example of narrative charting, this time with multiple sequential entries:

EXAMPLE: Pt with tracheostomy on the rehab unit.

0700 – Assumed care of pt after reporting on the primary nurse. Received pt in bed, resting quietly with eyes closed. Easily aroused to alert and fully oriented state with voice. Client indicates by shaking head that presently he has no needs and no pain or distress. Respirations even, unlabored via tracheostomy. Pt is receiving humidified oxygen @ 28%, 6 liters, via trach collar. SaO2 97% on continuous pulse oximetry. Trach site is midline and patent, and trach collar is secure to site. Breath sounds are course, with diminished air flow @ bases anteriorly and posteriorly. Suction, ambu bag, and oxygen set-up are at bedside. Pt HOB is mid Fowler’s. Instructed to call for any needs; pt verbalized understanding. Call bell within reach, SR up X 3, bed low position with wheels locked. Will continue to monitor closely.

0730 – FSBS 280 per glucometer # 4. 6 units Novolog insulin administered subcutaneously under supervision of instructor @ left upper outer arm. Pt tolerated well. SaO2 98%.

0820 – Eating 1800 calorie ADA breakfast (no fluid restrictions) without any signs or symptoms of aspiration. Feeding self; indicates he needs no assistance. Scheduled medications administered without difficulty. SaO2 96%.

0900 – Pt given Percocet 5/325 mg oral dose per request, in anticipation of scheduled occupational and physical therapy. SaO2 97%.

0915 – OT in room with patient. Pt indicates that he is tolerating therapy well. SaO2 98%.

1000 – Pt denies pain. Rates pain 0/10. Physical therapy at bedside. Pt taken off unit via wheelchair with portable O2.

1100 – Back to room; indicates he tolerated physical therapy well. Denies pain. Hooked back up to humidified oxygen 28% 6 liters, SaO2 98-99%. Tracheostomy care performed under supervision of instructor. Inner cannula changed out. Site without erythema or discharge. Skin intact. Patient tolerated well. Pt denies need for suctioning at present time. Only small amount of thick yellow mucous noted, which patient adequately coughs up.

1130 – FSBS 205 per glucometer # 4. 4 units Novolog insulin administered subcutaneously @ right upper outer arm, under supervision of instructor. Pt tolerated well. Denies any needs. SaO2 98%.

1200 – Sitting up in chair. Eating lunch in no acute distress. No changes noted from earlier assessment. Trach remains midline, patent, and intact. Humidified oxygen 28% 6 liters via trach collar, continuous pulse oximetry. SaO2 96%. Call bell within reach. Reported off to primary nurse.

(This is just an example. Be sure any abbreviations you use are approved by the facility and your instructor! Otherwise, write out all abbreviations such as "pt" and "FSBS"! :))

[Daytonite, BSN, RN]

I just have to post this because it kind of relates to this thread. I was in the hospital for surgery this week and in between the pain and the grogginess, I had a good time schmoozing with the various RNs assigned to me. I want you all to know how important good documentation is. The hospital nurses worked 12-hour shifts 7a to 7p and 7p to 7a. Around 10am yesterday I walked out into the hallway and found my 7p to 7a RN sitting at an isolated desk toward the far end of the surgical unit--CHARTING! This was no new graduate as we had several conversations. She felt, as I did when I was actively working in the acute hospital, that it was more important to stay and finish charting and make it as thorough as possible.

Now, she may have a time management problem, but I cannot say. However, her purpose was certainly clear. She wanted the work she had done during her shift to be correctly and completely documented because you never know who is going to be looking at what you've written. I never apologized or complained about the times I stayed over to finish my charting. And, if my bosses gave me grief about it, I clocked out and finished my charting on my own time because I felt it was for my professional and personal benefit. There's no way I was ever going to have to be on a witness stand and be made to look like a boob by an attorney. If you've never seen it, watch the movie, The Verdict, and how the attorneys treat the doctors and the nurse who changes the outcome of the malpractice trial the story is about. While a lot of it is done for dramatic purposes, the real deal can be a lot harsher and colder. At one of the legal seminars I attended we were shown a 15-minute video of a nurse being questioned by an attorney. It was awful as the attorney pointed out all the things the nurse didn't do or chart what she had done. The lawyer made the nurse look incompetent. And all he did was act polite and ask nice questions that were designed to bring out the flaws in her documentation that he wanted the jury to hear. On top of that he had a huge blow up of her actual page of nurses notes for the jury to see. They were sloppy and there were several places where she had scratched out the information she had written (wrong way to correct a document).

[VickyRN, MSN, DNP, RN]

Hand-off is the provision of verbal and/ or written information from one primary health care provider to another so that pertinent care, treatment, or service needs as well as the patient's current condition and any recent or anticipated changes are accurately communicated.

SBAR is an acronym for situation, background, assessment, and recommendation.

Situation: Identify the patient and who is involved. Identify the problem/diagnosis, recent changes.

Background: Review of systems, pertinent medical history (allergies, code status, chronic diseases, and disability), safety/ cultural issues, precautions, labs, medications, mobility status, mental status, next of kin, equipment, tubes, drains, medications, IVs

Assessment: Plan of care, summary of current condition, catheters, drains, lines, tubes, treatments.

Recommendations: Pending tests, suggestions or requests, physicians' orders, what is to happen, where, when, and how, to-do items, anticipated changes, and outstanding issues.

http://www.ihi.org/resources/Pages/Tools/sbartoolkit.aspx

SBARGuidelinesFinal.pdf

SBARWorksheetFinal.pdf

[Daytonite, BSN, RN]

Recent threads that might be of interest to some:

https://allnurses.com/how-make-soapie-note-t182629/

https://allnurses.com/dar-note-help-t182516/

https://allnurses.com/help-p-I-e-charting-t216348/

[VickyRN, MSN, DNP, RN]

PowerPoint on Nursing Documentation from Delmarlearning.com:

Basic Nursing: Foundations of - Skills & Concepts (PPT)

[SpookyCat, BSN, RN]

huladancer said:

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 amazon.com that shows the cover of the book. Hope it helps.

I just bought this and it should arrive tomorrow. I hope I didn't waste the little cash I have as a student. However, I need all the help I can get when it comes to charting. Even though we do our clinical at a hospital which uses document by exception, our instructors make us do narrative. I hope this helps.

[Apollorn]

SpookyCat, can you give me your verdict on that book once you get a chance to read through it? I'm interested in buying that exact same book but I am definitely short on the funds!

[SpookyCat, BSN, RN]

tanthalas said:

SpookyCat, can you give me your verdict on that book once you get a chance to read through it? I'm interested in buying that exact same book but I am definitely short on the funds!

Sure! Easter break starts after last class later today. I have clinical next week and plan 2 use it then. I'm going 2 go over it during break. I'll let you know if it works out or if its worthless.

FYI, I read somewhere that Chart Smart (ISBN: 1582559872) is also good. No personal experience with it though.

Take care, Good Luck, & TTYS!

SpookyCat

In the meantime does anyone out there have any serious complaints about the Charting Made Incredibly Easy book? or is it a good buy?