Struggling with thorough head-to-toe assessment and narrative charting...

Published

Specializes in LTC/SNF.

So far the only thing I am having a problem with in nursing school is time management, and more specifically, completing the giant mountain of clinical paperwork every week in a timely and efficient manner. We provide TOTAL care for each resident/patient assigned to us, and we are required to chart in narrative format a complete head-to-toe assessment at least once per shift. We are not allowed to chart by exception. EVERYTHING about the patient (even normal stuff) must be charted sequentially. My instructors want to be able to close their eyes and picture everything about that particular patient. We are talking 5-6 pages of narrative charting per shift per resident for LTC :no:. I get why they are making us do this, so that we become observant nurses who know how document well, but it is just so time consuming and difficult to remember everything that they want us to write down. In my mind, charting by exception makes more sense and that is what most facilities "in the real world" do. It is getting a little easier the more that I do it, but I am wondering if anybody has any tips/tricks on how to be more efficient, or maybe links to helpful handouts :loveya: Last semester I saw a fellow student that had a list of charting adjectives broken down by body part/system...wish I remembered who it was :/

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Go here I think this is what you need.........

https://allnurses.com/nursing-student-assistance/student-resources-narrative-427052.html

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

http://www.wfhealthcare.org/Wheaton/Employment/agency_staff/modules/instructor/HED/Charting_Tipsheet.pdf

HEAD TO TOE ASSESSMENT NARRATIVE NURSES’ NOTES INFORMATION FROM OTHER SOURCES (INTERVIEW, CHART)

Orientation

person place time

Levels of consciouness

awake alert confused agitated

lethargic unresponsive

[h=1]Behavior/Mood[/h] pleasant cooperative anxious

withdrawn sad combative

Speech

verbal non-verbal slurred

language barrier

Vision

glasses contact lenses

Pupils

Size______mm.

equal round reactive to light

Hearing

hearing aid: left right

Nasogastric tube

Oxygen

_____L./min.by____________

Oral cavity

moist dry

pink pale cyanotic

dentures partials caries

edentulous

Temperature

oral_______F./C/

tympanic membrane______F./C.

[h=1] [/h][h=1]Chest CXR[/h] Respirations

rate______/min.

rhythm: even uneven CBC

depth: shallow deep unlabored Hemoglobin

dyspnea short of breath Hematocrit

Cough RBC

productive non-productive WBC

sputum: color_____ odor_____ Platelets

consistency_____ amount_____

Shape of thorax EKG

A-P diameter WNL barrel chest

symmetrical

kyphosis scoliosis lordosis

Breath Sounds

anterior: CTA adventious

posterior: CTA adventious

lateral: CTA adventious

Heart sounds

site: mitral pulmonic aortic

rate:_____beats/min.

rhythm: regular irregular

Abdomen

Bowel sounds

RLQ RUQ LUQ LLQ

normoactive hypoactive

hyperactive

Soft, non-distended Firm, distened

Flat rounded obese

Gastrostomy tube (PEG)

solution______________

rate________ml./hr

intermittent continous

residual_______/ml.

Extremities

Color

race/ethnicity

cardiorespiratory status

Temperature to touch

Moisture

Edema: pitting non-pitting

Capillary refill: (one finger in each

hand)

Blood Pressure:______/______LR

Extremities (contiued)

Peripheral Pulses

radial

strong equal

palpable/Doppler

rate____/min.

rhythm: regular irregular

amplitude: ) 1+ 2+ 3+

brachial

dorsalis pedis

posterior tibial

Venous return

Homan’s sign: L R

varicosities

Sensation: itching trmors paralysis

numbness tingling

dressing:_____________

Skin

Color

Temperature

Moisture: diaphoretic desquamation

tending

Condition/location:

ecchymosis(ses)_____________

rash:______________________

macules papules pustules

vesicles crusts fissures

ulcers

edema anasarca ascites

Intravenous:

site:__________

solution______________

rate_____________ml./hr.

_____________mcg./kg./hr.

Incision

OTA Dressing

open closed: staples sutures

Steri-strips

approximation

length:__________cm

width:__________ cm

depth:___________cm

drainage: dry

wet: amount________

color__________

consistency________

odor____________

Pressure Ulcer:

location:______________

stage: I II III IV

dressing:___________________

ADDITIONAL DATA

Urine

Color

Clarity

Odor

Urine Output:______ml./______hr. BUN

Frequency/Pattern of Voiding

_______times/____-hr. Urinalysis

dysuria urgency hestancy

retention continent incontinent Urine C&S

Catheter: Type__________

Bowel Elimination

Date of last bowel movement:

_____________

Continent incontinent

Color

Odor

Consistency

Amount

Hemoccult: Postive Negitive

Nutritional Status serum glucose

Weight________lb.kg. albumin

Height________in./cm transferrin

Ideal body Weight________lb./kg. lymphocytes

Diet:___________________ cholestrol

Appetite:___________% eaten Total

Fluid intake:__________ml./hr. LDL

HDL

K+

Na+

Ca++

Cl-

Pain: Yes______ No______

Location:________________ PRN pain meds

Provacative/palliative

Quality/quanity

Region/radiation

Severity

Timing

Activities of Daily Living

Gait:steady unsteady

ROM: full limited

Bathing : S A T

Grooming: S A T

Feeding: S A T

Toileting: S A T

Transfer: S A T

Equipment (list)

Assistive ambulatory devices

TED hose

PAS compression stockings

Braces, slings

Heel/elbow protectors

Social, Cultural, Developmental

Interaction with:

Significant other

Health care team

Social support:

relatives

friends

church

Socioeconomic status

Cultural group

Religion (see cover page)

Developmental tasks for age group

Up Vote Up Vote ×
+ Join the Discussion