Nursing Documentation

I'm so glad you posted the critical thinking flow sheets. I'm new to this and they are really going to help me get organized. Thanks!

For my health assessment class, we also focused heavily on documentation. We were required to buy Physical Examination & Health Assessment by Carolyn Jarvis and it helped me a lot because they would examples of sample documentation, both for normal and abnormal, and as it went through each part of each system in the chapter it would also tell the norms and abnorms. It really is a great book and it was pretty easy to read.

They also told us that if you see something abnormal, just document exactly what you see.

Hi! How do you record on the medication chart when you are withholding a drug until the doctor has been informed? for example, after checking the BP of a patient, it's below 90/60 thus furosemide is withheld. how do you record that? thanks!

Hi this is my first year, I am desparate in need help to start me off with a progress note for dressing a skin tear wound. if anyone can assist that would be great:uhoh3:

Hi can anyone help with a progress note for a skin tear, this is my first wound assessment. really not sure how to start it off

You can also expand on the SOAP format by making it a SOAPIER note. subjective, objective, assessment, plan, intervention, evaluation, reeval if needed.

And DAR-data, action, response keeps you organized.

I've always preferred soapier notes.

Hi, I'm new to this website and I think it's a great place for info. Can someone give me a little help with my nursing diagnosis. A little background first. Patient is having a bowel resection within the next few days and has an active infection (pneumonia), she is also anemic and her religious belief forbids blood products. So I think the most important diagnosis would be Risk for shock but it's the related to part that always gets me, mine seem to never be good enough for my instructor I can't include the surgery because she hasn't gone through it yet, but what about risk for shock related to active infection and low RBC count secondary to anemia? Any thoughts? Thanks in advance.

Sorry this question is in the wrong forum :0

I am a new RN here in the US, and I am still struggling with my charting,back with then when I used to work in Saudi Arabia in a private hospital with less staff nurse, we tend to do more (hands on) rather than documentations, especially when we're being assigned in Dr where we have 5-6 deliveries and I or 2 of them will be CS, we hardly had time to document accurately we just write the time of the delivery and the intervention etc. short and simple. The nursing home where I work now seems the same, we are 2 nurses on the floor and 1 nurse aide, I am assigned to giving medications and treatments and hardly have much time in charting since I am the one who always help with the 2 assists patients, by the time I sit down and start my charting I almost forget what I did (interventions etc.) but yeah, keeping a pocket notebook helps a lot, writing down even the keywords to remind me about what happened during the shift with the assessment has been really helpful.