I am a nursing student and on med surg floor this term. I use a narrative charting template provided by our school which was used when I was on my medicine floor. My instructor will check our draft before we can transcribe to the progress notes.
For charting by exceptions, she always said that I missed important data and was not happy on my charting AT ALL. She said I should chart by actual or potential problems and recommended to use DAR format when charting. I tried my best to do so but still having problems! She said my charting did not reflect my critical thinking of nursing process.
In our program, we will do thorough patient researches and medications before clinical, so we would anticipate patient's problems. I did thorough assessments every time but identifying a problem/problems is not easy, especially when the problem I do not anticipate (example: I have a post op day 1 patient who shows s/s of sepsis). I do not know what I could do to help my nursing process and better charting. I am confused. Please help!!!!