Tips on proper documentation

Specialties Med-Surg

Published

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!

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

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

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

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

check you pm's!!!

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

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

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

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

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.

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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