nursing notes (assesments)

Follow the body systems for assessments. Be sure to cover everything:

VS, N, CV, R, GI, GU, Integ, IV. See example:

VSS. AAO x 3. RRR, no edema. Pedal pulses strong and regular. Respirations even and nonlabored. Abd soft and nontender. BS x 4. Last BM 8/8/08. Pt voiding clear yellow urine s difficulty. Scattered bruises on LUE r/t multiple IV attempts. Pt has 20 g IV to R wrist, flushing s difficulty. D51/2 NS @ 100 mL/hr. C/o cramping pain 3 on scale 0-10 to RUQ, relieved with Tylenol 325 mg. No c/o nausea. Pt resting comfortably. Husband at BS. SR up x 2. CB in reach.

That seems to be sufficient for a fairly negative assessment. Are the students doing this and still being criticized? Are you perhaps missing something important?

Good charting for assessments are accurate and objective. Many aspects are covered on the electronic flow chart and a written/texted in nurse's note is all that's needed to finish the assessment's documentation. Chart what you see when you walk in, what you did while you were in the room, how you left the patient/their condition/pain level. Chart they have their call light in reach/their SR status for safety issue. Better to chart too little rather than too much. Always chart objectively and remember, if it didn't get documented, it didn't get done (even if it did!).

:wink2:

your are charting for the next nurse and for your attorney. Both may need to get an accurate picture of what went on during your shift.

wow that was explained well--and no iam not charting that way-what they want gets changed so often that we are confused on wha t and how it is to be done.-we are in a nursing home so does nursing home charting different then hospital charting--it seems we have to put what they ate and how much,when i think iam doing ok--guess what iam not..does it take time to reach your charting potential...iam a student LPN

chart from head to toe

There's a really great paperback out called:

Surefire Documentation: How, What, and When Nurses Need to Document

Its good because it teaches you how to document correctly regardless of what field you're working in and gives good technique that will save you in the future if God forbid something needs to go to court!!

Check it out..its not that expensive - well worth it.

I start my assessment head to toe:

Pt. arrives from OR drowsy but easily rousable, Follows simple instructions, denies pain. Skin W/D/P, IV site without redness or swelling. VSS, DSG D&I to abdomen with no S&SX of bleeding. Foley draining clear yellow urine. Hemovac draining small amt bloody drainage. Moving all extremities, cap refill WNL, +PP bilat. Will monitor.