handwritten charting

  1. My teacher wants me to be a pro at charting, but I've had very little experience and no teaching. Is there a book or some resource to I can read to get better at this?
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    About truckinusa

    Joined: Jul '10; Posts: 273; Likes: 93


  3. by   AndrewCraigRN
    May I say that you will probably not be a pro at much of anything while in school except reading pathophysiology, looking up medications, and creating care plans.

    With that being said, this is an answer for google. I typed in, "nursing documentation resources" or, "nursing documentation examples" and came up with some decent examples.

    Charting, by hand or manually, is likely a skill mainly developed out of school. Your fundamentals book or other nursing books will have charting advice/tips. Check out the index. Furthermore, I would venture to say that charting by hand is a dying art because of the computer programs out there.

    Continue searching on google. Save your money. Google is free, practically infinite resource.

    Good Luck.

  4. by   Esme12
    There are different "formulas" to follow for narrative charting. These will vary facility to facility. A common mnemonic......SBAR.

    SBAR is an acronym for situation, background, assessment, and recommendation.

    Situation: Identify the patient and who is involved. Identify the problem/diagnosis, recent changes.

    Background: Review of systems, pertinent medical history (allergies, code status, chronic diseases, and disability), safety/ cultural issues, precautions, labs, medications, mobility status, mental status, next of kin, equipment, tubes, drains, medications, IVs

    Assessment: Plan of care, summary of current condition, catheters, drains, lines, tubes, treatments.

    Recommendations: Pending tests, suggestions or requests, physicians’ orders, what is to happen, where, when, and how, to-do items, anticipated changes, and outstanding issues

    This thread is old and some of the links might not be active but it is a great thread on documentation.
    Nursing Documentation

    From VickyRN asst admin.....

    Attached Files