Charting do's and don'ts

Nurses Safety

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Specializes in none, still looking.

What are the correct terminology to use when charting on the nursing notes? ex. use eyes closed vs. awake, in no pain

Anybody understand!

:uhoh3:

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Specializes in Rotor EMS, Ped's ICU, CT-ICU,.
What are the correct terminology to use when charting on the nursing notes? ex. use eyes closed vs. awake, in no pain

Anybody understand!

:uhoh3:

Possibly not.

Are you talking in general, or specifically regarding the neuro exam? Also, what unit, what kind of patient (adult, pediatric), and what diagnosis?

I.e. a neuro patient requires a more focused neuro exam. Maybe they are sleeping, but easily awake with verbal stimulation, or tactile (tap them on the shoulder), or possible require a combination of verbal and tactile (you have to say their name and tap them at the same time to wake them), but don't have to resort to painful stimulation.

You could be vague, and say "awakens with stimulation." Maybe you could be more specific and use the type or combination of types of stimulation, and chart the immediate response. I.e. "Awakens (I hate the word "arouse"), with loud verbal stimulation and immediately falls back asleep." Chart if this is a change from the previous exam. Chart the level of orientation if the patient remains awake and can participate, i.e. follows commands, oriented to person, place, time.

Really, just document the facts as they relate to your patient.

Maybe this isn't what you were looking for?

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Specializes in Geriatrics, LTC.

I try to chart like you should. You can't say someone is asleep, maybe they just have their eyes closed. A typical day with a patient resting I would chart something to this effect: (mind you I work in LTC)

Res resting quietly in bed with eyes closed. No s/s or SOB, no s/s of pain or discomfort. O complaints voiced. Arouses easily to verbal stimuli.

And if they have been up then I describe that and a general idea of what they have done that day (activities, PT...etc)

I have seen some charting that really takes the cake, I mean bad bad charting.

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Specializes in none, still looking.

Thanks

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

To describe a sleeping patient, I will chart, "Resting with eyes closed. Respirations even and unlabored. Arouses easily to verbal/tactile stimuli."

The 'respirations even and unlabored' statement is important because it indicates not only is the patient alive, but they're in no distress.

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Specializes in Rotor EMS, Ped's ICU, CT-ICU,.
To describe a sleeping patient, I will chart, "Resting with eyes closed. Respirations even and unlabored. Arouses easily to verbal/tactile stimuli."

The 'respirations even and unlabored' statement is important because it indicates not only is the patient alive, but they're in no distress.

I try very hard not to AROUSE my patients!!!!

LOL!

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Arouses easily to verbal/tactile stimuli."

Tactile??? This struck me as pretty funny too :monkeydance:Ah, our minds are in the gutter this afternoon. ;)

I am not sure exactly what the OP is asking . . . . I do chart "Asleep with even and unlabored resp." because it has always bugged me that I'm too unintelligent to tell if someone is sleeping or not.

steph

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

willdgate. . .yes, i understand what you are getting at. you need to see some samples of narrative charting. i've listed some links for you to look at some. remember that you need to keep your charting factual. mostly, you will learn how to do this by looking at the way other people chart. one of the best things you can do is get copies of the nursing notes by exception (check off notes) that are so popular now. many times these have the normal assessment items on them put in the way we used to document them years ago. so, every time you go to a different facility, see if you can get one of these forms, if they use them.

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.

http://www2.nursingspectrum.com/ce/self-study_modules/course.html?id=393 - "document it right: a nurse's guide to charting". a 23-page article that addresses most styles of charting and covers many common nursing situations.

https://allnurses.com/forums/f205/examples-charting-138835.html examples of charting for students

http://www.mededcenter.com/module_viewer.asp?module=+118#headtotoe - at the end of this article is a sample of how to chart a patient assessment.

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I am guilty of "arousing" my pts lol I have thought about it especially when I write something about arousable to light touch :lol2: I guess it is just habit now but still does not sound very appropriate.

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Aroused! Don't some of them wish? Sorry, guys, could not resist. LOL.

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Specializes in gen med surge.

You guys are naughty nurses.

lol, naughty nurses

Here is what my charting usually sounds like:

"Pt. resting comfortably with eyes closed. Respirations equal and unlaboured. No sign of acute distress noted. Will continue to monitor."

"Pt. awake, alert, and in no acute sign of distress. Pt. verbalizes no complaint or need. Will continue to monitor."

A lot of times I'll chart their respirations at the same time as I chart their "activity" note.

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Specializes in Emergency.

"Alert, calm, skin warm and dry, easy resp, steady gait, NAD, no complaints." This is my basic charting and exceptions can revolve around it.

"... ataxic..."

"... increased resp rate and WOB..."

"... appears anxious..."

"... c/o nausea..."

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