What do you appreciate about another nurse's charting?

[soffy]

Hi everyone,

Being a new nurse, I would love to pick up some good habits for when I chart. For example, what qualities do you appreciate in a well written progress note? Are there things that you find often in progress notes that you find redundant and/or are useless? Do you prefer concise note-form,or full sentences? On my floor, I am not restricted to charting in a specific manner so I'm working on developing my own way of documenting that nurses will appreciate and find helpful..

Any advice would be great! I really would like to work on becoming a "considerate" nurse.. one of those nurses that you like working with or right after.. you know??

[Dolce, RN]

I appreciate specifics rather than general statements. For instance a nurse could chart, "wound care done." That doesn't really help the next nurse reading the chart. A better way to chart is to include dimensions, character, smell, drainage and painfulness of the wound--along with the specific wound care ointments/treatments and dressings applied. This applies to any kind of treatment that is provided to the patient--specifics are always a good thing.

Mental status is a huge area that can be overlooked. Don't chart, "patient is pleasant, alert and oriented x 3" if they are not exactly all of those. Even minor changes in behavior--such as avoiding eye contact, appearing agitated, verbal outbursts, and disoriented speech need to be documented. It is very alarming to read in the chart that the patient has been A&Ox3 for every shift and then--all of a sudden--they have word salad. Baseline and follow up charting for mental status is essential to ensure that there are not neurological changes going on.

[MAISY, RN-ER, BSN, RN]

Paint the picture you see...if you had to go to court, don't you want to get the whole picture?

i.e. HTN/chf/DM patient BP/BG(DKA borderline) skyhigh, eating chips, drinking fluids, eating candy, drinking soda or whatever else....how can you help them if they are fighting you all the way! Needs to be noted in chart, you can guarentee if something happens and you don't have it....it just appears that your interventions didn't work, meanwhile every action performed has been counteracted by their inability to follow orders!

How about patients that develop dvt because they refused to move OOB, wear teds or use machine?

How about patients that refuse to use incentive spirometer, sit up in bed, move around and develop pneumonia?

And the list goes on.....size, ability to move, appetite, cognitive ability, socialization, family (everything that goes with that), and whatever else.

Maisy

[blondy2061h, MSN, RN]

Are you saying to actually write things like "borderline DKA" and "skyhigh?" The first makes a medical diagnose, and the later doesn't sound very professional and could be interpreted a number of ways.

[MAISY, RN-ER, BSN, RN]

Are you saying to actually write things like "borderline DKA" and "skyhigh?" The first makes a medical diagnose, and the later doesn't sound very professional and could be interpreted a number of ways.

Sorry if I wasn't clear...

No, basically giving scenarios....it's quite a picture to paint for a potential jury....patient with sky high FS or Hi BP eating chips, disregarding physician orders for DASH/ADA diet, families that bring in tons of crap to eat-refusing I&Os, daily wts or restricted fluid intake-eating candy, and whatever else.

Since the OP is a new nurse, I believe he/she has been educated to the "nursing" things to write, just not the CYA stuff to write when she's got non-compliant patients, or patients with non-compliant families.

Narratives are worth their weight in gold....statements like respirations ez and unlabored-no distress noted-sleeping supine and appears relaxed -call bell and family member at bedside....paint a picture that if a family member states later that the patient said they were up all night in pain, is easily disputed BY YOUR OBSERVATIONS/NOTES.

Anyway, I also think it's okay to refer to dx in notes if previously written by physicians. Our risk management loves my charting, so I guess I am doing the right thing...Even chart the note taking families...who I sent over, and what interventions/interactions occurred.

Maisy

[RNsRWe, ASN, RN]

I think the others pretty much said it all! For me, I'd just be happy to see that you charted what you DID with the patient--not what someone else told you THEY did. Don't chart what a wound looked like if it was under a stack of bandages and the previous nurse told you what HE saw. Chart what YOU saw.

Don't chart that you gave all kinds of hygiene care if you didn't. If you didn't and I then had to do it all, it looks like either this patient is a hygienic mess, or perhaps I just repeated what you did--and I'M the one who DID it.

Don't write "no change from previous assessment" if you haven't charted an assessment note to start with! It can't be "no change" from what the LAST nurse charted--again, YOU didn't do that assessment.

Pay attention to why the heck the patient is there in the first place. It's nice that you went on and on about her nausea issues and stable vital signs, but what about that giant chest tube and wound vac? Are they still coming out of her body?!?

Stuff like that

[TigerGalLE, BSN, RN]

I like clear concise charting. I hate it when your patient is declining and you go back to see how the previous shift was and you have nothing to go on. Or if a patient had a fever the day before and you go back and read the nursing notes and no one even mentions the fever. You always need to paint a picture with your charting and always CYA. And I like to always chart things that are in their body that are not naturally there.. IVs, Foleys, Chest tubes, Dsgs, PICC lines, Oxygen, NG tubes, peg tubes ect... what do they look like? any s/s of infection? is the dressing intact? clean?

For example;

0715: Report received from ___ ____, RN. Assessment complete per flowsheet. Pt lying in bed. Resp even and unlabored. 02 on a 2L via NC. No distress noted. 20g IV gelco in R forearm intact, SW, site without redness, edema, or pain. Foley patent draining clear yellow urine. Pt A&O x 3, pleasent. States, "I feel better today, I think I'm almost ready to go home." Denies pain or needs. HOB elevated, side rails up x 3. Call light in reach. Encouraged to call for assistance. Verbalized understanding -------------------------------------RN

1010: Pt c/o chills. Temp 101.4 orally. Dr. SoAndSo paged-------- RN

1015: Spoke with Dr. SoAndSo via telephone. Orders received for Tylenol 650mg PO Q6 hours prn Temp > 101.-------------------RN

1025: Tylenol 650mg given PO for fever. Pt denies other complaints, pain, or needs. No distress noted. Encouraged to call for assistance. Verbalized understanding------------------------------------RN

1125: Temp 98.4 orally. Pt states, "I feel much better." -------RN

1200: Pt OOB in chair with assistance from physical therapy. Pt eating lunch without complaints. Call light in reach --------------RN

Ect... Ect.... When I go back and read other nurses charting I like to be able to see what happened during that shift. Did they eat? Did they have pain? Was their dressing changed? Did they ambulate in the hall with PT?

Tiger

[ilstu99]

Accuracy!!! My favorites from the last month or so:

Weird - it looks like the record says my patient is on 6L HFNC, and has been charted as that every hour for the last 12 hours. Yet....when I look at the flowmeter, it reads 3L, and the RT's Q3 notes also say 3L. Hmmm.

You did oral care? Really? Cause there's something fuzzy growing in there that has its own zipcode. So is there some kind of infection, or other issue I need to be on the lookout for? Cause that's an abnormal amount of ick.

The PIV is infusing? Like....every hour, it has been infusing? Can you...ummm...show me where it is? Because for the life of me, I don't see one.

Did you think it might be a tad important to mention that mom collapsed at the bedside last night? Or that she suffered a loss in this unit 2 years ago? Or that she let slip that she has Hep B?

And the narrative notes should be just that - this is the specific problem, this is what I did, this is how it went, this is my next action.

Thanks for asking! I wish everyone cared enough to ask. :)

[leslie :-D]

i can tell you one of my pet peeves regarding charting:

"pt denies pain"...and that's it.

no notes about the soft groans, clenched jaw, fisted hands, rapid resps...

no notes about the very vocal protests from families who don't want the pt all doped up.

no notes about the pts who do refuse pain meds (and so, deny pain) r/t a fallacious belief system.

but according to the nn's, one would think they're just breezing through their disease process.

and lo and behold, there are always a few grieving family members who accuse us of letting their loved one suffer until their very last gasping breath.

to read the nn's notes, one might even believe these family members.

so please, jot down everything...

conversations, physical presentation...

any/all subj and obj data that relates to the care (or lack of?) pt is receiving.

it very well may just save your hide.

leslie

[MAISY, RN-ER, BSN, RN]

Oh I know what we all forgot, the appearance/disappearance of wounds. Good God! Even in the ER we hold patients and it drives me crazy! Some mention of site, appearance, and exudate would be nice. OR it's noted for one shift, but ignored for next two shift and then reappears!

Also any type of output would also be nice. I can't stand when a nurse(giving report) has no idea if a patient had a bm or is passing urine...and I am ER! When FIL was ill this was key to his SBO/renal failure-no BM and diminishing urine output-nothing noted for a couple of days. Hmmmm think thats a problem?

Or how about the patient that keeps taking off their oxygen? Someone better be noting that.

There are just soooo many things, you have to note what you observe, and what patient's condition.

Maisy

[Dolce, RN]

I always like to include an actual quote from the patient--especially as it relates to their mental status. Example: Pt states, "I played Marilyn Monroe in the movie Cabaret." Quotes like that paint a thousand words about the mental state of the patient. (The man who actually told me this was a patient from the State Hospital).

Also, it is helpful to document number of times needed to reorient or redirect a patient. There needs to be thorough documentation of problems prior to placing a patient in restraints or giving a medication such as Haldol. If they were "alert and oriented" in the nurse's notes and yet the MAR documents Haldol being given prn throughout the shift that is a major inconsistency.

[nerdtonurse?, BSN, RN]

First, good question!

Be accurate, clinical, factual -- rather than "patient is combative" put "patient attempted to strike nurse in face with telephone, overturned IV pole, ripped out IV and threw bedding, screaming, cursing, demanding to go home; pt is from LTC Such and so. Security called to assist in applying restraints to allow nurse to apply dressing to bleeding IV site and administer haldol 5mg IM." That tells them this person is physically violent to the point where you needed help to keep them safe.

If you've got a person who's circling the drain, put WHY. Put "patient is bleeding from old IV sites r ac, top of r hand, requiring doubled 4x4s and tape to contain bleeding; also around R subclavian TLC, large amount bright red blood requiring pressure dressing and 5 lb sandbag to prevent additional bleeding, stat APTT > 250, Dr. so and so notified at 2314" not "patient bleeding everywhere."