Questions on charting

[Meika9501]

I need some help on charting. Can someone help me on what you should always write down and what you should never write down. certain words that should never be used ex- tolerated well, what should you put instead? What should be charted if you start an IV? i'm a nursing student that needs some advice. Thank You.

[truern]

Say you ambulated the patient 20 feet down the hall. Okay, you want to chart that he tolerated walking that far...how do you KNOW that he tolerated it? What was his heart rate? How was his breathing? Could he speak without being short of breath? Did he have pain with ambulation? How was his color? How much assist was needed? That factual data is much more accurate than "pt tolerated well."

IVs: What size angiocath? How many sticks? Location of IV? What IVF is infusing and at what rate?

As Joe Friday would say, "Just the facts, ma'am."

[magicmommy]

It might be helpful to take the time to read other nurses charting especially those who have years of experience. Don't be afraid to ask your coworkers for advice. It's about teamwork, even with charting. I always feel like I am trusted when another nurse asks me what I think about her charting and asks for help with it.

[Meika9501]

Thank You for the helpful tips.

I not able to go through other nurses charts because I'm in school and I'm not currently working. But thanks anyway.

[TheCommuter, BSN, RN]

For legal reasons I always chart, "Call light within reach; patient states will call PRN."

Do not ever chart that the patient is in pain without charting on the actions you took to help relieve the pain (medication, distraction, etc.). Avoid using adjectives (easy, well, good, poor) as much as possible since they indicate your subjective opinion. If a patient tolerates a meal well, you should be able to chart, "Consumed 100 percent of breakfast." It sounds a lot less subjective than "Patient tolerated meal well."

Remember that the facts are concrete, but subjective findings are always subject to differing interpretations.

[Meika9501]

Thank You TheCommuter.

[TheCommuter, BSN, RN]

I need some help on charting. Can someone help me on what you should always write down and what you should never write down.

I shall also add that Lippincott sells a book entitled Charting Made Incredibly Easy. If you are willing to invest in another book, this might be the one.

[Meika9501]

thanks i just bought it yesterday.

[TheCommuter, BSN, RN]

thanks i just bought it yesterday.

Come back and tell us how you liked the book.

[Meika9501]

so far it's been helpful. It gives little examples and lists what needs to be included for each topic Iv's, esophageal tube insertion and removal,transferring a patient, CPR, and many other topics. I like it.

[suzieqlpn]

My lpn program required the purchase of a procedure manual for all sorts of things...catheters, enemas, injections, dressing changes, etc. It also included assessment.

I just about wore the book out. It was very helpful. I also found that for an assessment it was helpful to write it out on scrap paper and read it back to yourself before it went into the chart. I always destroyed the scrap paper, of course.

I was always proud of the fact that my instructors would send other to me when they needed help with charting.

[BlkQueenLPN]

I always in with "no acute distress noted (NADN)-call light within reach-will cont to monitor"