wengrn

charting is an old issue in the college of nursing... when i was a student we used to follow the so-called SOAPIE (subjective, objective, assessment, planning, intervention, evaluation... duh!) in charting... as for me i don't need to chart something that is already existing in the assessment form, waste of time... with lots of paper works on the floor (especially when you have an admit), we tend to focus on the paperworks rather than the bedside care... something that was so frustrating for me when i was following up my students in the floor... just write what you see and do... assessment on lungs, abdomen, skin, etc - don't they appear in your assessment form? if there's any changes you see from the skin integrity on the previous day's assessment (e.g., it became worse), that's the only time you chart it... the VS? do we have to put it in the narrative report since it appears on the VS sheet already? if there's any issues about the vitals, write it... like, "BP suddenly dropped to 70/45, called the doctor, and made order..." make the narrative report (or charting) clear, concise, specific and short... that way, we have time to run when our dear patients call us and not making them wait because of the bloody paperworks kept piling up to our neck!