jennahousern

I understand your pain, however, pt charts are legal documents. When notes are not done correctly to include proper spelling or grammar there are adverse effects. The bottom line is that it could harm the pt, an error in doc. can kill a pt cause malpractice and negligent lawsuits and maybe even cost you your job. ultimately, you are correct in trying to improve upon these skills. Take a writing course, use spelling check and or type note in a word program where grammar is checked and then cut and paste to its proper place. If its a paper chart then this is a little more difficult to do. Good luck!

@giada23 I can see why you are doing what you do when it comes to documenting. I use to be a Medical Assistant Instructor and we did teach that we have to document what the patient states and to do it in their own words. However there is a limit to this. Do you remember the 6 C's of charting? 1.Client words 2. Clarity 3. Completeness 4. Concise 5. Chronological order 6. Confidentiality This is a good technique for keeping for notes short and sweet, but to the point and with the accurate information. Nurses can use this techniques as well. SOAP notes, though, is a documenting format that is used to get the nursing process on the way. This is by finding out the Subjective data (CC), Objective data (measurable data), Assessment (deciding what is wrong with the pt) and Planning (what to do). After this, the ADOPIE is put into practice which is Assessment, Diagnosis, Outcome and Planning, Implementation and Evaluation. This is a mouth full. But each individual practice has the same general idea/format for documenting the same thing. For the part where you have to put what the patient says into a note, what nurses do is to paraphrase: write what the patient said, put it into a medical note, using proper medical terminology and anything that stands out as important put into 'pt stated' and then use a "quote". I hope that this helps. Sorry, I'm wordy too. ?

Thanks for your time...:redbeathe

I am writing a thesis and need a lot of help...Currently writing about the importance of proper documenting. I have a mini survey, I am hoping you can help with. 1. What type of documenting system do you use? (Narrative, Soap, etc.) 2. What are the most common errors you see when reviewing notes from other nurses? 3. What do you think can be done to help fix documenting problems? (eliminate abbreviations, EMR, etc) I appreciate any feedback...this is going to be shared with first year nursing students and they need all the help and advice they can get. Jenna

dear lcamp85, i am sorry to hear that you are not loving your new career. but i think that this is completely fixable. if you really hated it, you would have not finished the program. you do like nursing, you just dont like your job. you just have to find a department in which your happy and hours that will allow you to practice safely. it sounds like the night shift just isn't for you. start looking for another position. talk to your hr maybe you can be transfered. burnout is very common in our profession and its to early for this to happen to you. so in the meantime, try to get rest. do something to pamper yourself and start looking for something else that will make you happy. think about the kind of nurse you wanted to be when you were in school. is that what you are doing now? if not then why? i hope this helps. good luck to you.

I think that you will do great! I am sure that you have done everything you could to prepare. Good luck and of course, keep us posted!

For a Psychosocial Care Plan, how about "Impaired Parenting"? If depressed, "Hopeless"? "Impaired Social Skills"? I am just throwing out ideas to get the juices in your brain flowing...

At this point I would say for you to try and do something to relax. You have done everything you can to prepare and you either know it or you don't. I would rest, go for a walk, get a pedicare, be hydrated and get a good night's sleep. Don't worry, you will do well. Good luck and see you on the other side of nursing!

I agree with ashleyisawesome and I would change the phrasing to: Pt is an unemployed 41 year consequently living at home and unable to provide for his child. Then adding diagnosis, or reason for hospital visit and your nursing interventions.