Nursing Documentation

[redred]

Hi guys-

I'm a new nurse and I'm looking for a good reference for nursing documentation. Can anyone refer me to some helpful books and aids.

redred

p.s. I'm working on a cardiac stepdown/telemetry unit

[RNAnna]

Hi Redred,

The Nursing made Incredibly Easy series of books has one specifically on charting. I've never looked at it myself, but I've heard good things about it. There are also quite a few books about nursing and the law - which is what charting is all about. Go to amazon or barnes and noble and do a search on nursing documentation. There may even be a documentation book in Mosbey's little pocket handbook series. This may even be a good question to post in the specialty pages so you can hit a few more nurses in your field. They might know which resources will fit your specialty the best.

Anna

[MedSurgeMess]

Hi Redred,

The Nursing made Incredibly Easy series of books has one specifically on charting. I've never looked at it myself, but I've heard good things about it.

I've got this book, and it really didn't help too much. I have learned more about documenting from people that I work with, reading others notes, etc. Ask a co-worker, who is a valued info source, to show some of their documentation and to also look over yours when you do it. If you feel uncomfortable for a while and you do handwritten documentation as opposed to computer documentation, then write it out on paper first and have someone else look at it. If you do computer documentation, type it out then have someone else review it before you hit 'Save'. I hope this helps. I am new and have had an awful time with documentation, but have found these hints to help me a little.