progress notes

[cayenne06, MSN, CNM]

Just curious. I work in LDRP and noticed that all of us seem to have very different charting styles when it comes to progress notes. Some of the nurses seem to chart every detail of every interaction, like "summoned to room by call bell, pt found in left lateral position, desires extra pillow. Pillow obtained from linen closet, pt placed it between her knees. Denies any additional concerns/complaints, advised to call if she needs anything else." I would not have charted ANYTHING about that interaction at all. I would have given her the pillow and called it a day.

Now, my patients are usually healthy pregnant or postpartum women and their babies. Of course ADL things like getting extra pillows might be more important if we are talking about someone with COPD or something. Well, at least I would assume so- I've actually never worked outside of LDRP so I really don't know!

Of course all meds/interventions are charted in the appropriate spot, but I don't usually write an accompanying progress note unless there is a specific issue or related assessment that merits explanation. Like, if I give a multip some oxycodone for her afterpains, I wouldn't chart anything beyond her pre & post pain scale and the dose/route/time etc, unless there was something out of the ordinary. I wouldn't do a progress note about plain old cramping.

I'd love to hear how other nurses use their progress notes! We use electronic charting, if it makes a difference. What do you deem "progress note-worthy?"

[VANurse2010]

"summoned to room by call bell, pt found in left lateral position, desires extra pillow. Pillow obtained from linen closet, pt placed it between her knees. Denies any additional concerns/complaints, advised to call if she needs anything else."

Haha, whatever! Must be nice to have time to chart baloney like that.

[amoLucia]

I'd bet the nurses who chart extensively (like OP's example) are newbie grad nurses. Like charting for nsg school.

Wonder how there's any other time left over for other things when so much time is spent on such charting.

[Here.I.Stand, BSN, RN]

If I need to include more detail than what I can describe with check boxes, it becomes a narrative note. Pt grimacing and clenching teeth, HR increased; increased the fentanyl to 100 mcg/hr, one hour later pt has no nonverbal of physiological indications of pain doesn't go in a narratie note because all of that information can be entered into the pain section of our VS/infusions flowsheet. Pt's ICP increases to 30, I will write a note so I can elaborate on the changes in the neuro exam and what we did for the pt. Just a couple of examples there.

I'm all about working smarter, not harder, and entering info twice is def working harder.

Spelling out in paragraph form that the pt rang her call light and I offered a pillow...really? Nope, I'm too busy caring for pts and making sure I get a lunch break to spend time typing stuff like that.

[Double-Helix, BSN, RN]

It really depends on your floor's policy. Some use a "chart by exception" approach where only abnormal findings, or findings that are not elsewhere documented require mention in the note. Others prefer that at daily note be written in SBAR or ADPIE format.

I've worked in both kids of units. One required a full note on every patient, including a paragraphed summary of the problems, assessment findings, interventions, and results for the day. The other only required a note if there were something significant that happened os something that couldn't be documented anywhere else in the chart.

I'd suggest talking to the nurse manager on your unit to review the charting policy.

[guest2210]

In electronic charting, there is very little need for the nursing staff to chart a progress note, IF everything they document in the doc flowsheet is there. They can even write a quick note in the specific row of the flowsheet on anything abnormal. Of course, a progress note can be done for anything that needs more extensive documentation.

[caliotter3]

I'd bet the nurses who chart extensively (like OP's example) are newbie grad nurses. Like charting for nsg school.

Wonder how there's any other time left over for other things when so much time is spent on such charting.

I used to follow a nurse who charted in this manner. Every period had its own period, and every T had two crosses. It caused me to notice, in various ways, that evidence of her work did not leave a trail of consistent superior job performance, if you know what I mean. The sad thing about it, is that the client noticed this too and brought it to my attention.

[dudette10, MSN, RN]

That interaction could have been charted differently and actually been useful to other nurses reading it. Nowhere in that note is the assessment of *why* the patient wanted the pillow. Was it a pain relieving request?

"Patient rated back pain 4/10, pt in left lateral position, provided a pillow between the knees per patient request. Pain level reduced to 2/10 immediately."

There's a reason we should chart in SBAR or ADPIE or whatever. It makes our charting relevant and useful to the team.

[dudette10, MSN, RN]

In electronic charting, there is very little need for the nursing staff to chart a progress note, IF everything they document in the doc flowsheet is there. They can even write a quick note in the specific row of the flowsheet on anything abnormal. Of course, a progress note can be done for anything that needs more extensive documentation.

Disagree. Where I work, docs read our notes, and they don't even have access to our assessment flowsheets. While I do review the preceding nurse's last assessment on the flowsheet, her note is usually more concise and easier to read.

[VANurse2010]

Disagree. Where I work, docs read our notes, and they don't even have access to our assessment flowsheets. While I do review the preceding nurse's last assessment on the flowsheet, her note is usually more concise and easier to read.

That sounds like a double charting waste of time to me.

[dudette10, MSN, RN]

That sounds like a double charting waste of time to me.

While it is double charting, there is no other way to communicate with the docs in the chart. Anyway, it's a JC requirement to address the plan of care during the shift, so we all write our notes through the POC module.

[VANurse2010]

While it is double charting, there is no other way to communicate with the docs in the chart. Anyway, it's a JC requirement to address the plan of care during the shift, so we all write our notes through the POC module.

Sound like your PCS/EMR needs to go. And who are these doctors who read nurses notes anyway? Don't you all talk?