Nursing Progress notes

I am a bit confused because the hospital told me to disregard everything you learned from nursing school. They said they don't want the details of each system because that is what the assessment is for.

Actually the orientation I had in my job didn't tell us anything about progress notes. I just assumed I would be doing what I learned in nursing school. The nurse who worked with me yesterday said "didn't they tell you we don't chart like we were told in nursing school?" I ran into a writers block and didn't know what to do.

Okay. I will ask my manager. I apologize for asking assistance related to my job on this forum .

I was told the same thing when I started my first job. In my situation, it meant all the detail I had grown accustomed to in school wasn't necessary. My first few months on the job, I'd write a half page note addressing everything I had observed head to toe because in school instructors assumed if you didn't write something it meant you failed to notice it- if you didn't write HR RRR S1 and S2 noted, then you didn't assess heart sounds properly. In other words, 'if it wasn't written it wasn't done'. My co-workers insisted I was working myself to death trying to include EVERYTHING. Charting by exception for us means if it's a normal finding upon assessment then you don't have to address it in the progress note. Any abnormal finding should be noted (ie lungs with bilateral I & E wheezes).

You also learn to narrow your focus depending on what the pt Dx is... you might not even write anything regarding bowel sounds in a pt on a regular diet hospitalized with COPD but would write several lines on lungs sounds, respirations, O2 Sat etc. I have to admit charting a book on every patient is a hard habit to break. I still find myself doing it sometimes, but when you have 7+ patients you learn to omit every word you can after you've had to stay 2hrs late following a 12hr shift to get your charting done a couple of times!