Topics About 'Charting'.
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Found 34 results
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Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill:
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Hey everyone!
I have been an ER nurse for the last 5 years in a level 2 trauma center. Obviously the last 2 have been especially difficult. Between ER holds, increased patient acuity and short staffing there are times when I am in a critical p...
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My hospital is gearing up to move to a newly built hospital. I'm excited about this but am wondering about a few new approaches management wants to try. The first is computer charting in the rooms. We have to have computers in the room for medicine s...
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Working as a private duty nurse, you spend extended times with your patient and their family. How would you consider charting if family issues are directly affecting the patient (ie causing -extra- stress, anxiety, depression due to fights occurring ...
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Though it can vary by state, typically the statute of limitations to file a medical malpractice lawsuit is two to three years. Though most claims are settled out of court, if it does go to trial, the average malpractice case takes 3-5 years to resolv...
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At my facility, we have two areas of charting--the MAR and the TAR. The MAR is obviously for medications. The TAR is for treatments and other orders such as vital signs and when to notify the provider. Lately, I've been finding that nurses are del...
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Does anyone know if there is a good website available that shows examples of narrative charting? I have noticed that charting is a real weak spot for me and some of my fellow students. It is difficult trying to remember what needs to be included and ...
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First and foremost, the medical record is a permanent aggregation of various documents that should furnish a comprehensively accurate picture of a patient's health status while he/she stayed at the hospital or other type of inpatient facility. After ...
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I usually chart "Pt appears to be sleeping, no respiratory distress noted" is this sufficient for charting that a pt is asleep? I heard that we should chart pt IS sleeping as it becomes a legality issue. What do other RN's chart when a pt is sleeping...
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What are DAR Notes?
The DAR framework is a form of focus charting, and it stands for Data, Action, and Response. This system is a great way to organize notes, understand patients' priority issues, and assist with communication between the myriad ...
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The long term care industry (a.k.a. nursing home industry) employs a large share of new and experienced nurses in the United States. Furthermore, the number of nurses who secure employment in this specialty is projected to increase in the next ten ye...
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Working in Remote AreasWhile working for Health & Welfare Canada as a community health nurse, I received advanced training for outpost nursing at Dalhousie University in Halifax, Nova Scotia. In our training, we were taught the cardinal signs for...
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I have been accused of false charting vitals. It's an on going investigation with HR at the moment. I am currently enrolled in nursing school and I don't want to have to drop out if they find me guilty. I never purposely charted wrong. We are always ...
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Dear Beth,
The small company I worked for sold to a publicly traded health care company in July 2021. We switched to an EMR which requires false information be entered in order to advance the program (one example: entering a value using the Edmo...
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When charting on a patient in long term care facility, please give an example of a good nurses note.
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We all know we have to keep it objective and professional when we write a note, but clinical notes are really masterpieces of restraint. They summarize our chaos in a way that makes us look like Daenerys Targaryen calmly walking through fire as every...
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The medical record is a permanent collection of legal documents that should supply an all-encompassing, accurate report concerning a patient's health condition. Physicians, nurses, social workers, dieticians, mid-level providers and other members of ...
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Hello, I need your help with regards to Focus Charting or FDAR Charting. Though it has been implemented to other hospitals, the hospital where I work at is just implementing it next year. I am currently assigned in the Emergency Room where what we mo...
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When a patient vomits theoretically there is always the risk of aspiration. I can never think of what to write after I write "patient vomited 30 ml's green tinged fluid." Do I write "lungs CTA." Do I write "no apparent distress." Do I write "VSS"? I ...
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I've been out of nurses for a while, actually unemployed. I can't remember how to chart lung sounds. So confused. If its the right upper lung is it the patients right side? If the nurse is facing the client and she is listening on her right side is i...
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I am a nursing student and need to practice DARP charting. I keep making up my own scenarios in order to do this but it is really hard to make up the scenario and then DARP chart about it as I keep coming up with the same things over and over!
I...
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Is there a website or books to help me about nursing procedures documentation? I'm having a hard time documenting the procedures that I have done.
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Hi, Everyone! I am new to this site and I have some few questions regarding the medicare charting guidelines. Does anyone know where I can get a copy of this? I just started a new position at LTC and I am responsible for charting on all Medicare resi...
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I need assistance in finding some medicare charting templates that assist the nurses in charting on the medicare patients. Does anyone have some they can share? Thank You
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Hello everyone, I was wondering if any of you folks use EPIC to chart all your notes, procedures, etc. We just started it 4 weeks ago and unfortunately I was out with a bad contact dermatitis for the first week. We are all overwhelmed with so much in...