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.

[suebird3]

I NEVER write that resident fell. Slid/found on floor.....no problem.

Suebird

[jaimemds]

Never chart I in reference to yourself, only in quotes as the resident stated it. never chart told resident to go to room, or put in room to calm down. this is considered isolation. Never chart med errors. And never include in the note any staff's quilt regarding an incident, i.e. supervisor failed to notify MD of blood sugar 459 or CNA did not place call light within reach.

[nursinginstructordmy]

There are some practice in charting assessments at http://freenursetutor.com Go to the assessments topic and you can actually assess the patient and then write your findings and check it with what was written. Try it.

[katie258]

Just a wee hint from a fellow student, if you give analgesia, go back and ask if it worked, and then chart.

[Meika9501]

Thank You for ALL of your help I will check out that web site nurdinginstructordmy thanks again.