Paper charting

[sasrn0988]

I'm a new grad currently in the middle of orientation at a hospital that is still using paper charting, at least for a while. I was wondering (for those of you who currently use it or have used paper charting) what you put in the nursing notes/nursing narrative. My preceptors have said I need to work on this as my notes are too vague. Sometimes I feel like I am double charting things that are located in another part of the paper chart. If anyone has any suggestions as to what is most important to put in the nursing narrative please share.

[Tait, MSN, RN]

I paper charted for the last five years. Basically we had "charting by exception" which meant the following:

There was a checklist of systems for each patient on the form. When a patient was admitted you put a * to show the assessment was comprehensive. So for neuro you would chart a check mark * if everything within the assessment was normal. If it wasn't you put * and wrote something like A&OX3, hard of hearing right side, uses hearing aid.

And so on and so forth for all the assessment categories, including P/S, IV etc.

On subsequent assessments you could arrow over any continuing, but unchanging variables. For example: Cardiac: If the patient was admitted on tele, has remained in the same rhythm, lets say NSR you could arrow over and skip re-charting on it.

If something had changed however, you would put an * in the box. Let's say the person was admitted for a gangrenous toe, but then started having chest pain on your shift. This prior normal would not have a star and your note would read: 04/01/2013 2200 Pt stated radiating chest pain from the left chest wall to anterior shoulder. MD informed and pt placed on tele reading 1st degree AV block. CP protocols start...etc etc.

Anyway the point is charting should be concise. You should be able to go back and read the charting five years later and know exactly what what going on the day you charted it basically.

So let's say you have the following patient: 23 y/o female, s/p appendectomy, pain level 5/10, IV Dilaudid available Q2 hours 1-2mg severe pain, percocet 1-2 tabs Q6 hours for mild pain. Four laps sites with bandages.

Just give me a mock write-up on what this patients assessment might look like. Then maybe we can see what your instructor means by vague. If you want to :)

Just a thought,

Tait

[nurseprnRN, BSN, RN]

I always thought that a systems approach kept me organized. Top to bottom:

Subjective: Whatever the patient says to you when you say, "How are you today?" :) or ask some question specific to C/C

Objective assessment findings:

Neuro: level of consciousness, pain, gross neuro function (moves all, weakness, paralysis, special senses)

Cardiovascular: color, diaphoresis/dry skin, edema, rate, rhythm, pulses, perfusion, heart sounds, daily weight, I&O, CBC, lines

Pulmonary: rate, lung sounds, SpO2, subjective shortness of breath, or not, ability on incentive spirometer, sputum...

GI: Swallow, diet, nausea, BM, bowel sounds, NGT output, whatever's specific here; liver/pancreas sx/sx prn

GU: U/O voided/cath, color, residuals, related labs

Ortho/extremities: mobility, pain, contractures, whatever applies

Skin condition, wounds, healing

Psycho/social: spiritual, affect, behavior, pain, visitors, family, fear, patient teaching/feedback

Assessment:

Whatever I think-- normal postoperative course, progressing per clinical tree, whatever nursing diagnoses come from assessment

Plan: for what I want to do today

What tait says about someone reading your charting years hence is spot on. I read charts for a living and it's astonishing how little you can take away from an extensive record when nobody bothers to do assessments (or let me know they have done any)..and sometimes that's really, really, really important.

Charts have a bunch of different uses: communications between disciplines, legal description of care given, teaching tools, back-up for billing, audit for systems research, risk management tool, staffing planning, nursing and medical research ... your goal is to tell all of those people what you, as the nurse and expert in nursing care, can add to their data set. One of THE nicest things a doc ever said to me was that when he read my nursing notes he could just visualize the patient and what was going on with him/her. (Thanks, John Mehigian, wherever you are.)

NANDA-I 2012-2014 is very helpful with sorting things out. You can find any number of resources in your textbooks for nursing documentation, too, and I know Esme has some good links for various charting schemata.

[hiddencatRN, BSN, RN]

We are transitioning to computer charting soon, so right now our flowsheets are all paper. We chart by exception so only write notes if there's something to write a note about and otherwise the routine stuff just gets checked off. Do you have to write a full note about every patient?

[sasrn0988]

I definitely like the way you said you should be able to see exactly what went on during the shift. That's something that I will be keeping in mind during my next shift.

I do fine when charting the shift assessment and reassessment on the flowsheet, it's just the notes that I struggle with. For instance, this is how I would start one of my notes, but some nurses have told me this is too vague.

0730-assumed care at the bedside from noc rn

0815-assessment complete, no cp, sob, denies pain. vss, will continue to monitor

anyways, that is just an example of what we are expected to do. One nurse said if my notes are too vague then it looks like I haven't done anything for the patient even though it is charted elsewhere on the assessment flowsheet. I just want to understand/gather more info on what others write in their notes and if anyone writes out extensive notes about the entire day, including routine activities, like some nurses I have worked with.

[applewhitern, BSN, RN]

What is your hospital's policy on charting? For years, I charted narrative style, as taught to me in nursing school. Then I went to work at a hospital that wanted you to chart by exception only. Yes, you will double or triple chart stuff. That is very common in the nursing world, and will still be true with computer charting. If you have a checklist, use it, then chart by exception. If you do not have a decent checklist, then just narrative chart. Start with a "head to toe assessment," then chart anything that changes. Chart at least every two hours, and chart things you or your patients do, such as "ambulated 20 yards with minimal assist." Have you read the notes your co-workers write? That might help.

[chrisrn24]

I definitely like the way you said you should be able to see exactly what went on during the shift. That's something that I will be keeping in mind during my next shift.

I do fine when charting the shift assessment and reassessment on the flowsheet, it's just the notes that I struggle with. For instance, this is how I would start one of my notes, but some nurses have told me this is too vague.

0730-assumed care at the bedside from noc rn

0815-assessment complete, no cp, sob, denies pain. vss, will continue to monitor

anyways, that is just an example of what we are expected to do. One nurse said if my notes are too vague then it looks like I haven't done anything for the patient even though it is charted elsewhere on the assessment flowsheet. I just want to understand/gather more info on what others write in their notes and if anyone writes out extensive notes about the entire day, including routine activities, like some nurses I have worked with.

Maybe with your note say things like "Pt sitting up in bed eating breakfast, husband present at bedside. assessment completed. T 98.2 R 18 and non labored o2 sat 92% on RA BP 134/57 P 57 and regular. Neuro exam..." and so forth.

I work in LTC but to me it's a pain in the butt when people write "VSS" because if I want to

Know them, I have to look at the time of the note and go into a different section of the chart and find the vitals that match up with that time and its a pain. It may be repetitive to note them but it may be better in the long run.

[sbostonRN]

We have an extensive flow sheet so I tend to not document twice. In my narrative I document their vital signs, progress towards discharge, if they worked with PT/OT, and a focused assessment. If they're there for respiratory, I chart their lung sounds, any neb tx, dyspnea, etc. If they are cardiac, I document tele rhythm, apical heart sounds, rate. If they have a wound, I document assessment and progress. I also note that lab values were reviewed, any new orders, any antibiotics, med changes, safety monitoring (like 15 minute checks, restraints, etc). And of course if there is a change in status I am much more thorough in the charting.

[CodeteamB]

I think that if you have charted something on a flowsheet or electronic record it is beneficial to note that in your narrative. Eg:

"Pt sitting up bed, resps unlaboured, denies shortness of breath and chest pain. Patient c/o pain 8/10 to LLQ abdomen requesting analgesia, see MAR. Abdomen remains soft to palpation, tender to LLQ. Pt nauseous but denies vomiting, refusing antiemetic at present. Vital and neurovital signs stable, see neuro sheet."

This way you mention that you have completed further assessments without double charting them, and make it easy for anyone reason the chart to follow your thought processes and find the info they are looking for.

[sasrn0988]

Thanks for the responses! I will be trying to incorporate some of this info along with what my preceptor's have said into my future notes.