Tips on proper documentation

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I finally set my foot in the med surg unit for to days last week...I was so nervous at first being out of nursing for a while..and this is my first exposure to a US hospital too.

I just wanna ask for some tips about proper documentation. ..the do's and dont's. I would really appreciate it and put it to use.

Thanks!

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ooopppsss....I mean "two" days...sorry.

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Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.

Most hospitals here have flowsheets which are pretty self-explanatory.

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Follow the policy of your hospital and use the guidance of your preceptor.

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check you pm's!!!

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CYA!! (cover ya azz....)!!!

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Most hospitals have an "approved list of abbreviations" too.

I agree with asking the preceptor how they want it done there.

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there is a book called charting made easy by springhouse which shows you several forms of charting, i hope this helps

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Specializes in OB, Telephone Triage, Chart Review/Code.

My hospital won't let us use cc anymore. We have to use ml. The docs are also having a hard time with this. Have to do what policy says. You should get plenty of help from your preceptor.

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Check out sites listed at google.com:

http://www.google.com/search?hl=en&ie=UTF-8&oe=UTF-8&q=Proper+Nursing++chart+documentation

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