Topics About 'Charting'.
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Found 36 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, looking for some input on your end of shift note. I'm a second year nursing student and I struggle with this. Each of my clinical instructors have had different requirements for it, and of course each facility I am in has a different EM...
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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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If a medication is given late is it proper to change the time to when it was due and chart medication administered in a timely manner late entry due to resident cares?? I noticed many older nurses doing this…or leaving the meds uncharted or refused i...
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I’m about to complete my first year as a BSN graduate and as an RN. I currently work at a PCU/Tele unit in a stroke/chest pain center. We see patients with medium to high acuity, our usual staffing ratios are 5 patients per nurse, and 3 CNAs for the ...
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I admittedly have anxiety and struggle with respirations. One night my respirations were 21 and I kept counting until it reached 24. I told my nurse in case she wanted to verify. I don’t think she actually counted but I can’t prove it. I asked her we...
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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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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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As I sat on the couch in my patient's home, I could feel my computer drawing all the attention in its direction. Like some irresistible force, it seemed to lasso and pull away the family's eyes. I deliberately moved it to the side, setting it where I...
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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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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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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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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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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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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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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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Documentation and the average nurse is a hot topic, so you have to start as you mean to go on! Documentation in nursing varies a great deal, what you should document, what you do document and what you don't document. Documentation is a minefield. We ...
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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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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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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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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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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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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 charting on a patient in long term care facility, please give an example of a good nurses note.
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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 ...
