wow, broad subject. LOL
i guess i have a system but never really thought about it. it just developed on it's own.
i chart my initial impression of the scene when i go into a room. "pt sitting up in bed. safety rails up x 2. call light in reach. pt. laughing and talking with friends/family."
i then get a hx from the pt or family member.
then a focused assessment with any relating assessment factors. "crackles in bases bil. no lower ext edema noted." or whatever.
then i chart what i did about the assessment. "pt placed on O2. rt called for hhn."
that's the guts of my charting. but i also chart the little things. md to room, to ct per stretcher by rad tech on O2, po fluids given. tol w/o nausea/vomiting, etc.
make the time to chart even if it's "no deficits noted" because that says that you at least addressed the symptoms. a board of nursing isn't going to care if you feel it clutters up the chart. they will want the whole picture of care a pt received.
as far as trauma goes, GCS on arrival, any changes noted, and on discharge is my rule.
traumatic mechanism of injury always gets GCS, resp assessment, and belly assessment. "GCS ___, resp easy & even, no abrasions noted on chest, equal and even chest wall rise bil, BS clear bil per scope. Abd soft, nontender to palp, nondistended, BS x 4 per scope. urine sample sent to lab for eval."
keep your charting short, sweet and to the point but most of all CYA because it's your A on the line if/when that patient crashes. the procedural charting is important but the physical aspects of what you see is just as important. look at your patient.