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Reccomendations for good note taking?

Posted

Specializes in Home Care, Peds, Public Health, DD Health. Has 14 years experience.

I am wondering if anyone can reccommend a book or a site for helping with writing good notes? I have purchased a few, and they are more on making sure that you are documenting the correct things. What I am looking for is more the language that is used most often and normal documentation for each discipline. I just would like to work on bettering my notes. I look at other peoples notes sometimes and I guess I know I could do better, some peoples look more professional and some look definately less professional. In school , we noted vitals and much of what we did was noted on a 4 page chart that had nothing but check marks etc. it really does nothing to teach you anything but WNL etc, if there was something that was out of normal limits, then we wrote a note. so it isnt as though I dont know the terms, it is just that I feel I could definately stand to improve my note taking.

While the one company I work for seems to not want copious notes they definately need to be accurate and informative for the nursing company, insurance company and the doctor., the other company I work for seems to think the more notes, the better, we have to write something for every 30 mins to an hour of our shift.

Anyway, I would appreciate if anyone has any recommendations of either websites or books?

anangelsmommy, ADN, BSN, RN

Specializes in Home Care, Peds, Public Health, DD Health. Has 14 years experience.

Thank you! sounds great, and I found one of them for only $6 including postage! thanks!!

angels mommy