Examples for documentation.

  1. Hello,
    I would really appreciate if some of you nurses/students could provide me with some scenerios and how you chart it. For example, a patient came in with burns and had surgery etc. How do you chart the IV site, like the whole head to toe thing. I really need help with documentation...I'm really considering a class designed specifically for charting. Any help would be greatly appreciated!
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    About JesL2bRN2007

    Joined: Apr '07; Posts: 26
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  3. by   Daytonite
    very hard to find this kind of stuff on the internet because of hipaa and confidentiality issues. if there is a class you can take then take it. there are also books on the market on documentation for nurses. you should also do a search of this thread for "documentation" or "charting" as this subject comes up from time to time. here are a few links i have to samples of charting:

    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.

    https://allnurses.com/forums/f205/ex...ng-138835.html examples of charting for students with links posted by vickyrn

    http://www.medicalassistant.net/soap_note.htm - writing soap notes. includes links to sample soap notes at the bottom of the page.

    http://en.wikipedia.org/wiki/soap_note - soap note

    http://www.childbirths.com/euniversi...umentation.htm - concise information on the different types of charting formats

    http://www.nursingcenter.com/prodev/...asp?tid=622257 - ladies & gentleman of the jury, i present. . .the nursing documentation. a ce article from nursing 2006 on advice when charting patient care that may help you sidestep a lawsuit or be well prepared to defend yourself in court if you have to.
  4. by   Finallyat40
    Report received, care assumed, orders reviewed. Infant in isolette on servo mode set at 36.5. VSS. Orally intubated with a 3.0 ett, secured at 6.75 cm at the gumline, ventilator settings on flowsheet, Fio2 requirement .30. 6 fr OG placement verified X 2 with no gastric residual, remains NPO, OG open to vent. PICC to left forearm, dressing CDI, no redness or edema at site, infusing TPN at 3.0ml/hour and IL at 0.5ml/hr and fentanyl (10 mcg/1ml) at 0.12ml/hour to deliver 1 mcg/kg/hour. PIV to right foot remains hep locked, site without redness or edema, dressing CDI. Oral Care provided. Infant repositioned for comfort. Mother phoned for update, questions answered, encouraged continuing to pump breastmilk, will visit later. Will continue to monitor closely.

    Is that what you're looking for? Every nurse will chart differently when it comes to narrative charting. For me, the key is to be able to go back over that patient in your head and visualize everything you saw. If you miss something in your initial note....add it in when you remember it as a new entry. Some folks chart the head to toe way, while others chart by system....they're both right....they both accomplish the same goal....as long as you stick with one or the other....don't try to mix them up, because you'll end up missing things.

  5. by   meandragonbrett
    My typical narrative.....

    Report received, walking rounds completed. Assessment completed per flow sheet. SR @ 60-70bpm w/multifocal PVCs. NGT placement verified by auscultation. oral care provided. medistinal dsg dry and intact w/o s/sx of infection. R radial a-line patent with appropriate waveform noted and no s/x of infection. R TLC patent with nipride @ xxx, propofol @ xxx and esmolol @ xxx. R #18 A/C INT with + blood return, flushed with 5cc NS. IABP to R Femoral. No s/sx of infection. Timing 1:1. No apparent distress noted, family @ bedside x2. Family updated. Bilateral soft wrist restraints in place for patient safety. Bed in low position, side rails up x4.

    Just a brief (and incomplete) narrative. I don't typically rewrite anything that is in the flowsheet unless if there is something that is attached to the patient that is not present in normal everyday life. I don't chart normal findings in my narrative, only in the flowsheet. Good luck.