Understanding DR notes on pt. chart

[Jhernandez1294]

Im a first year nursing student, and today i was very discouraged. Can anyone please guide me with tips or helpful information in understanding the charts.

More specifically with meds and why they are prescribed them ?

As nurses we should know why this patient is on a certain med & the doctors will write it in the progress notes, today my nurse was trying to explain it to me & it was a foreign language.

I was trying to understand why my patient was on a million meds for a million conditions. learning all these abbreviations was overwhelming.

i looked up all my meds but never understood why exactly he was on them all. Reason why i need to better understand there notes,

(The handwriting wasn't a problem! lol surprisingly it was more abbreviations).

If anyone has any insight how they learned to read such information... pls help ! :) thank you

[Jenngirl34RN]

Really your best way of finding out why a patient is on a medication is to look at what that medication does and why it is prescribed (in general, not specifically to your pt). From there, you can look at the conditions your patient has and should be able to match them up. Looking through all of the patient notes is usually a pretty inefficient way of trying to figure that out, especially if they have been there for any length of time. Some of them may be drugs your patient takes at home and are not newly prescribed for the hospital stay. In that case they will probably not be in the notes, but you can always ask your patient why they are taking the medication if it is not clear after looking at their history. If you really cannot figure it out, you can ask the nurse you are working with, but I would make that a rare thing.

How far along are you in your program? Have you started pharmacology yet? Once you understand the classes of drugs it becomes a little easier to figure out why your patient is taking them. You will also see that a lot of medications are really commonly prescribed and you will get to the point you will just remember what they do and what they are for and what the nursing considerations are.