roenthatcher

Thanks for your reply verene. I kept my question pretty broad because I know schools can be very different in what they require their students to do. I was not totally sure what to ask about. For instance, you are the first person that I have heard of requiring hour logging. The differences are interesting. My school has a three page paper document. Page 1 is includes pertinent patient Hx, physical assessment, Morse fall scale, Braden skin assessment, vitals, pain scale, and questions about what is the most important thing to assess in this patient. Page 2 is choosing three problems and goals, and then space for a narrative. Page 3 is a care map that is supposed to include problems, interventions, labs, meds, and where they fit and how they connect. We do that for each patient. That is all we do. Our sites will not allow us to document in their EHR, and we don't log hours or anything else. My last semester we will have a preceptorship, and the documentation will be different there.

Hello, I am doing some research on nursing school documentation. I would like to know what your school has you document on. Do you use paper? Do you use the clinical site EHR? It would be particularly helpful if any of you can attach a picture/screenshot of a blank (no pt info) document. Ultimately, I would like to see what specific items are included in your documentation. Thanks for the help!