Teach me how to document--PLEASE!

Charting Made Incredibly Easy is a great book. I am currently reading it and it has helped me so much!

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 dont know if they still teach this but use SOAP notes. Subjective, Objective, Assessment and Plan. What the pt. says, what you see, your assessment of what you see and do and what you plan to do. This is very easy.

Another thing I do is just go from head to toe. Ie: mental status all the way down to ambulation and edema in the lower extremities.

-One thing that an "old" nurse can advise you and probably the most important thing I can tell you is DOCUMENT DOCUMENT DOCUMENT!!!! Everything always. Take credit for what you do, even if a patient is not having problems, document that. it will save you in the long run. When documenting, think of sitting next to the man in the black robe with a lawyer pounding you for answers. The answers should be in your documentation, if it's good.

look at it as if your trying to tell a story. talk about what you see, what you did, and your evaluation on your interventions performed, as well as anything significant that should be mentioned.

as far as shift reports, i have a list that i usually report to the on coming nurse. it consist of:

name and age:

code status:

diagnosis/history/allergies: Why they are there, hx of illnesses, and allergies.

medications: (important meds and why they need it) ex-hypertension meds, anticoagulants, upa tx, antihyperglycemics, insulins...

current status and interventions i did on my shift: ex-vss, pain meds, IV, PICC, wound vac, foley, etc etc...

Upcoming labs and diagnostics scheduled for future shifts: ex-CXR scheduled this morning, expected lab results, need stool sample...

you get the hang of it after awhile. good luck