Teach me how to document--PLEASE!

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Specializes in LTC.

I really need some help with documentation. During clinical, my instructor would tell me to write more and be more descriptive but never gave me any guidelines or expectations.

I will graduate--God willing--in 8 weeks and I am so excited and am really paying close attention to the nurses during this clinical rotation but I feel absolutely clueless about documentation and shift report.

Do I need a book? Is there a book? What about a website?

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Here are a couple of books on nursing documentation:

(a) Surefire Documentation

(b) Charting Made Incredibly Easy

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Specializes in ICU.
I really need some help with documentation. During clinical, my instructor would tell me to write more and be more descriptive but never gave me any guidelines or expectations.

I will graduate--God willing--in 8 weeks and I am so excited and am really paying close attention to the nurses during this clinical rotation but I feel absolutely clueless about documentation and shift report.

Do I need a book? Is there a book? What about a website?

I used to use a narrative approach but then found it was clearer using headings. For instance:

  • Respiratory
    • details of their respiratory system, how much o2 therapy (if any) are they self ventilating or having non invasive ventilation. Are they intubated? Details of arterial gases, or sats. Are they having nebulisers. Do they need physio? Do they have any secretions on their chest?

    [*]Cardiovascular

    • Details of heart rate, rhythm, blood pressure, pulse. Bloods sent today? Have they been reviewed, what if any action taken.

    [*]Renal

    • U&Es, adequate diuresis, are they catheterised, do they need assistance

    [*]Gastro-intestinal

    • Are they eating, or on enteral feed, or having parenteral nutrition. Can they swallow ok or do they need a speech and language assessment. Bowels opened?

Then continue with other systems such as:

  • Neurological and Pain
    • Is pt alert and orientated, are they confused?
    • Glasgow Coma Score.
    • What analgesia has pt needed? Was it effective?

    [*]Skin integrity

    • Wounds (type and location, kind of dressing, any drains, how much drained.
    • Waterlow score or whatever you use to assess the risk of pressure sores developing. What kind of mattress the pt is on. If not appropriate document clearly what steps you took to get the right mattress.
    • Is pt able to reposition themself unaided, or does it need nursing assistance (how many, did you need to use a hoist, slide sheet)

    [*]Infection Control etc etc

    • Samples sent, action taken. What I also do is provide details of any information I have given to the medical team and their response - for instance, pt has high white cell count - nil ordered. That way if trouble lays ahead you have provided evidence of your actions.

Put under each one whatever is relevant. Doesn't take long to do, I found that always using the same format means I am less likely to omit documenting something. Of course, the one thing you don't write down will be the one that you get called on later :banghead:

Hope this helps a little

Mary

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Specializes in ED, ICU, PSYCH, PP, CEN.

document what you see and hear. If lungs sound clear document lungs sound clear. Don't worry about using too fancy of medical language or such. Keep it simple. Remember if you don't chart it, it wasn't done.

For example, try to chart everything you do for a pt such as treatments, warm blankets, pillows, speaking to their families, doctors and any education you provide.

Just use common sense language and avoid abreviations as we are using them less now for safety sake.

Just chart what you did and when, and sometimes why.

For example: Crutch training given to pt and family, pt demonstrates safe use of cruthes.

or: 1800 ADA diet provided, pt ate approximately 90 % with assistance from wife.

Or: bedside commode provided for pt due to unsteady gait and weakness. Pt assisted to bedside commode. large bowel movement noted. pt requires assistance for hygiene

I have read a couple of books on documention and they helped a lot. Look in the nursing section at Barnes and Noble or other book stores.

I document as frequently and as much as I possibly can because this will refresh my memory on a patient if I am ever brought into court.

It also lets the higher ups know what you were doing and when so you have proof you were not eating bon/bons all night.

I have often been told I am a good documentor

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Specializes in LTC.

Thanks for your help. The examples and advice you all offered have been very helpful. What do you think about my shift assessment? Have I forgotten anything? Anything I should reconsider?

Pt is (race, age, sex) with severe CAD, CHF, Hx multiple MI, glaucoma, DM. Alert and oriented x3, denies pain at this time. VS 97.1, 66, 18, 73/36. Abdomen round, firm, nontender. IV lock in Right hand with no redness or swelling noted. Pt reported a period of paresthesia in Left arm due to laying on Left shoulder and fistula in Left arm. Pt reports normal feeling at this time. Slight nonpitting edema noted at both ankles. 2L O2, activity as tolerated. Pt is DNR, no feeding tube or urinary catheter. BP normally runs in 80s systolic but dropped to 70s most of the evening. MD was notified, came to assess pt. MD requested reassessment of BP in 1 hr, report to MD if no improvement. Cardiac surgeon talked to pt about AICD surgery scheduled for Friday. I viewed 2 videos with pt explaining AICD. Pt ambulated to hall to sign consent for surgery. Lower lung sounds were diminished. At 2000 pt requested 2 extra blankets, reported chills, cough. Cough resolved without intervention by 2100. Lisinopril and Carvedilol were held at 2100 due to BP 73/36. Pt refused miconazole at 2100. Patient was awake, laying in bed and watching TV when I left the room.

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Specializes in ED, ICU, PSYCH, PP, CEN.

Not bad for a beginner. Usually you want to leave out stuff like who the pt is and the dx as that is already noted in chart. also you can go through and slash out most of the time you used pt as we know who you are talking about. for example just put

refused miconazole at 2100, awake, lying in bed, watching tv. you don't need to say "when I left room" you could say "lying in bed, watching tv with no needs at 2200"

you will learn to use fewer and fewer words as time goes by.

we all do

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wow, i'm impressed. you are excellent as documentation, gonzo1. i'm an lpn student and the way i chart is soo amerture (sp?) compared to yours. lol. i do my clinical rotations at a nursing home and this is how my instructor has taught us to chart. received pt in bed at 0800. aao x __. tolerated ___% of meal with/ without assistance. (here i usual document any type of pain the pt has and my interventions.) perrla is wnl. apical rate is ___bpm. it is (description; note regularity, rythym). capillary refill is wnl. t_, p_, b/p__. respirations _ /minute are clear bilarterally and easily audbile. a&p lungs are _________. bs are ausculated on all 4 quadrants; __/ minute and are (hyper/hypoactive). pt can maew (or if not, i indicate what limitations the resident has). edema is/ isn't present. (if it is present, i note the type of pitting and location.) skin color is peach, warm dry, and intact. (i note any pt needs). call light left in place and instructed pt is call if assistance is needed. reported off to nurse.

so what do you think? is this good enough? :D:twocents::yeah::typing:nurse::nurse:

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Specializes in ED, ICU, PSYCH, PP, CEN.

You are definately on the right track. Documentation is hard and is an ongoing learning experience. Most everyone I know thinks documentation is the hardest part of our job. I still pick up tips all the time.

There is a computer charting system called Medhost that is in use at a couple of hospitals I work at and I love it. Point and click documentation.

If you have NSO they have lots of documentation tips on their website to help one avoid lawsuits. I bet you can read those even if you don't have their insurance. Check it out sometime

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Specializes in Everything except surgery.
I really need some help with documentation. During clinical, my instructor would tell me to write more and be more descriptive but never gave me any guidelines or expectations.

I will graduate--God willing--in 8 weeks and I am so excited and am really paying close attention to the nurses during this clinical rotation but I feel absolutely clueless about documentation and shift report.

Do I need a book? Is there a book? What about a website?

Your charting should start at the patient's head, and flow downward, addressing each system, with a relationship to the patient's diagnosis, making sure to use only approved facility recognized abbreviations This is the same way you should give report. Be sure to document in a clear, concise, relevant and timely manner, following your facility's requirements.

Many facilities have different requirements for charting, and everyone should know what their facility's SOP (standard operating procedures) are, as this is what will help you stay out of court. On day one of your new position, find it, and learn it!!!

Like someone said, chart as if you were in court and needed to remember what happened 2years ago, which is the limitation in many states for a lawsuit.

Good Luck!:smokin:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

there is a sticky thread with information and weblinks on the nursing student assistant forum that you should check out:

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Specializes in Biomedical, Hospice, LTC, Office.

I would leave out the medical diagnoses (CHF, multiple MI's, CAD, etc) because you could be accused of 'diagnosing' the patient, which can only be done by a physician. Also, I would have notified the physician IMMEDIATELY on a systolic bp "in the 70's". You will get called on that if you let it go most of the evening. Anything under about 85 is reason to notify the physician immediately if not sooner. Also, I wouldn't bother to mention the stuff the patient doesn't have (the catheter or feeding tube). No reason to write extra stuff. Also, if the patient reported chills and cough an additional temperature wouldn't be amiss. You wouldn't want to find out later that your patient had a temp of 102 right after you left the shift. Mostly, cover your bum by making sure that you answer all the questions that you bring up. If something is normal, there's really no reason to address it, unless the facility's policy is making you do so. There should be one complete head to toe assessment done every day, then after that the usual rule is charting by exception (if it's weird, write about it.)

I hope that's helpful.

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Specializes in LTC.

Thanks Dierdra. I think I am confusing my shift assessment with report for the oncoming shift. Maybe I should eliminate diagnoses for shift assessment and add them to the report? What do you think?

Thanks everyone for the input and advice. It is GREATLY appreciated.

***I am taking my practical nursing finals in 6 weeks and I am so excited I can hardly stop thinking about it!!!!!!!

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