in clinical, i was only exposed to "click click" "scan scan" computer charting, and making "clinical notes" as needed.
the tele floor i work on is a whole different way of charting.
it is our policy to chart by exception. the main part of this that i'm trying to get a good grip on is the 24 hour flow sheet and the nurses notes.
initially, i was trained on the way to open my note with things like vital signs and abnormals. gradually i've seen on an and by coworkers - don't double chart things like vs on nurses notes and on the graphic sheet b/c if a discrepancy was created on accident, it could knock you credibility in a legal arena. so, i started to get more careful.
on our 24 hour flow sheet, if something is "abnormal" we are to make a nurses note entry about it. usually if its weak pedals i'll say "bilateral weak pedals noted, skin warm and dry" if its adventitious breath sounds i'll say such "posterior bilateral lower lobes decreased, pt denies sob, resp even and nonlabored." those are things i'm okay with and come up with wording, state what i see.
lately, i find i'm staying at work till 9pm-10pm after shift trying to finish up charting because so much happened during the day, 2-3 discharges, 1-3 new admits, pain relief requests, pts receiving blood or returning from cath lab requiring q15 vs that i get so caught up in rooms that i get swamped with charting entries.
that's my goal #1, is to be more efficient at charting during the shift. my goal #2 is to learn more lingo to chart. (point of this thread =] )
i've read things like don't say "pt resting comfortably in bed, resp even and nonlabored" because how do you know the pt is "resting comfortably?"
i've had preceptors tell me "if something is not there or is not observed, such as you don't hear a murmur then don't say anything about it because what if you can't hear it? only say what you can assess, observe and what the pt states." it can be confusing. there are other cases where a preceptor has told me in reference to a c/o of 10/10 chest pain to notate "hob at 45 degrees, no facial grimacing noted, pt requests snack" (which was the case) those are the entries that don't immediately pop into my head as something to say.
so here are some questions i have..
- if the flow sheet has "pt safety check" on there and the option to check boxes for resp even and non labored and option to check for no c/o pain, would you use the flow sheet or nurse note q1-2h?
- if you gave a pain medicine at 1200 and at 1245 the pt is "sleeping" do you wake them up or do you entry "pt in bed with eyes closed, resp even and nonlabored, no signs of pain observed?" --- what signs of pain are you looking for a in a sleeping person? facial grimacing?
- if pt refuses to wear ted/scd/tele, i make entry and state education offered, verbally explained, needs reinforcement, those sorts of things.. do you call the md or do you wait for rounds?
i know part of it is i'm a two week old baby nurse and have a lot to learn. i read a bunch of threads on charting on here, i hope if the things i brought up on this thread will provoke some new thoughts, suggestions, from experience point of views on these types of charting entries and how to learn when you can make time to chart.
advice to get more efficient? advice on charting entries you've made or seen that could be better or worded differently?
I use the patient safety check on the flow sheet. If there is a particular issue, like a known DVT I'll document the extremity q1-2h "+2 pedal pulse, cap refill
I went to the bookstore today and grabbed a bunch of 1st year nursing and charting books, it's nothing I haven't really heard, its just a matter of me getting a grip on doing it under pressure. Right after something happens I feel so drawn to catching up on tasks that stopping to document seems like something I can make notes about and fill out later, but I am changing that school of thought. Documenting the event should be of equal importance with catching up. If something happens, pt condition changes, someone needs to read my notes asap, I need to have it laid out to be viewed.
Thanks for all your input, like to hear more. Hope this thread helps other newbies. As for the two week old comment, I feel like that :)
CoffeePVCs
15 Posts
DanaNP,
I use the patient safety check on the flow sheet. If there is a particular issue, like a known DVT I'll document the extremity q1-2h "+2 pedal pulse, cap refill
I went to the bookstore today and grabbed a bunch of 1st year nursing and charting books, it's nothing I haven't really heard, its just a matter of me getting a grip on doing it under pressure. Right after something happens I feel so drawn to catching up on tasks that stopping to document seems like something I can make notes about and fill out later, but I am changing that school of thought. Documenting the event should be of equal importance with catching up. If something happens, pt condition changes, someone needs to read my notes asap, I need to have it laid out to be viewed.
Thanks for all your input, like to hear more. Hope this thread helps other newbies. As for the two week old comment, I feel like that :)