BeaconRN

Hello I am also a new grad in a Med/Surg unit, and I am VERY glad my Preceptor is all about document!! document!!!& document!!! "care not documented is care not done". I have tried to "chart" as much as I can about my pts, we also document by exception. Like you, I was looking for a good book about documentation, I found "Documentation in Action" by Lippincott Williams & Wilkins ed 2006, I dont know if there is a newest edition. It is great book, it has a LOT of examples, notes & charts. It provides you with examples of daily documentation (basic skill) as for what to document during different challenging conditions. It also focuses on the legal & ethical implications of documentation as we know. It has hundreds of written nurses's notes that provide a model for your own notes. Well, just to let you know, I am going to look if there is a new edition. Good luck to you...

Thanks....totally agree!!

Take a look to his statement http://www.jarvikheart.com/news.asp?id=20

Soooooo true...they really don't get it...sooo frustrating!!!!!

My advise to you is also to keep fighting for your goals, you are almost there!!! I would like also to suggest to you that the night before your clinicals (when you go & review the chart), you may want to go & meet your patients if you are allowed to. Do a quick assessment & questions, and you will see how much more you can find about them...along with what it is already on the chart. Ask the RN in charge of the care of the pt that day......and I know, it is very difficult as students to review the pt chart especially around change of shift. Good luck to you!!!