Trouble with charting

Carla25 · May 29, 2007

I have the books Chart Smart ISBN # 1582550964 and also the book Nursing Documentation Handbook ISBN # 0323010970

anonymurse · May 29, 2007

If you are taking/giving verbal report, you can use the Kardex to note things like med times, significant problems/interventions/outcomes, FSBS and special notes. So you use it as a skeleton care plan and also to take and give report with. It's good to find someone to show you how.

I mention this because you can jot stuff down on it and use it to refresh your memory prior to charting.

Charting is mainly a matter of DAR, for each piece of Data that indicates a problem, you make sure you also chart your Action or intervention, then you must follow up with the patient's Response.

I have heard you shouldn't leave the patient's room before you've charted everything relevant to your visit. This works for me.

Some argue that you should chart out of the room so the patient won't use your silence to request you do little chores for them, however if you keep up a running conversation, and if you chart as you go, you should be OK.

Everyone has their own way of charting, and some nurses and instructors will nitpick your charting to death if it isn't exactly like theirs. Don't let it get to you.

Mostly, charting by exception works. Say if it's unusual for you to give 2 Percocet for a stated pain of 3/10, however that's what the patient says, and you know he lowballs the numbers, and he tells you that 2 barely works, then even if you are going to type in the numbers on the machine, you might want to chart the number but also note he requested 2 based on his experience with the drug.

You don't really have to make sense to the world, just to yourself as you're protecting your license, or as a student, your instructor's license. So if an instructor says "you shouldn't put AM care in there" and you say "yeah well the family was complaining how yesterday he didn't get a bath" then your instructor will see your point, or should.

KellieNurse06 · May 29, 2007

I was taught a really good way by my Maternity instructor actually.....I had trouble putting it all "together" until she showed me an easy way...and it stuck ever since.....she told us go head to toe........amazing how one basic little comment puts the pieces together....so that's how we would chart with our notes.....I still do it that way to this day.....

She said that if you can put together a picture of the patient that you can sort of visualize before even seeing the actual real patient, then that's a good way of charting.........and this instructor actually writes for Saunders NCLEX books.......so I know she knows her stuff really well....

GatorRN · May 29, 2007

Yes, I agree, head to toe assessments and charting have always worked the best for me too, as far as not leaving something out. You can always make yourself a little cheat sheet on the back of a card or something to refer to when you are doing your charting. Such as:

Vitals

LOC (a&o x3 etc..)

Eyes (perrla etc..)

Lungs (clear bilaterally etc..)

Abd (soft, non-tender, BS active x4 etc..)

Pulses

MAE (moves all extremities equally etc..)

IV's (location, type, size, fluid, rate etc..)

Foley/Drains (16F FC draining clear noncloudy etc..)

Skin Assessment

Sequentials/Teds

Safety (bed low, side rails up x2 etc..)

This is just a rough example. I'm sure you'll come up with something that may work better for you. Hope this helps a little. The more charting you do over time it will become second nature to you.

3KittiesRN · May 29, 2007

Thanks everyone for your replies! Those are some great tips! And thanks Carla25 I will look into getting those books!!

Lynda Lampert, RN · May 30, 2007

Okay, maybe this isn't the way to do it, but these are some of the things I've picked up so far. I hate, hate, hate narrative notes. I actually like to write, but narrative notes get me so stressed. I never know what to put.

Sometimes I will look at what has been written before me. I know that some nurses have bad habits, but I look at the general form of the majority of the notes. What are they noting? What did I forget to include? Did they notice something I didn't? What is their general form?

The second thing I found helpful was simple critque. Now, I never found the instructors's crituques very helpful. I was one of ten and they could not focus with me well enough to be as helpful as I needed. Actually, in my independent study, I worked one on one with my clinical nurse expert. I would submit my note on scrap paper to her before entering it into the final note. This gave her the opportunity to cross out what was unnecessary and add what I overlooked. Once I started seeing her pattern, I knew to do it every time. She needed to correct me less and less, and I felt comfortable writing it directly into the chart.

I'm still not too great with notes, actually. I start my new grad job on monday, so I feel like I will learn how to chart for the patients I am seeing. I'm still learning. And I probably will have my preceptor check my notes for the first week or so -- hopefully that won't drive him or her crazy. :)

Hope this helps,

Iona

Myxel67 · May 30, 2007

Most hospitals use some type of flow sheet which usually is arranged by system. The flow sheet is completed, then the narrative addresses only negative items. This keeps charting shorter and avoids double charting. If you check "lungs clear" on flow sheet, there's no need to include in narrative, unless pt develops wheezes or crackles, etc. later in the shift. Also if there's a box to check for bath, am care, hs care, etc, not necessary to write it. But if you had a pt who vehemently refused a bedbath, you could document that in the narrative. Follow the flow sheet and don't write any more than you have to.

ninfanp · May 30, 2007

Yes, I agree, head to toe assessments and charting have always worked the best for me too, as far as not leaving something out. You can always make yourself a little cheat sheet on the back of a card or something to refer to when you are doing your charting. Such as:
Vitals
LOC (a&o x3 etc..)
Eyes (perrla etc..)
Lungs (clear bilaterally etc..)
Abd (soft, non-tender, BS active x4 etc..)
Pulses
MAE (moves all extremities equally etc..)
IV's (location, type, size, fluid, rate etc..)
Foley/Drains (16F FC draining clear noncloudy etc..)
Skin Assessment
Sequentials/Teds
Safety (bed low, side rails up x2 etc..)
This is just a rough example. I'm sure you'll come up with something that may work better for you. Hope this helps a little. The more charting you do over time it will become second nature to you.

GatorRN, its clear guideline.hope i could'nt read anymore charting that stated "Rceived patient on bed ambulatory " and in NICu nurses note "No complain the whole shift" :madface: