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??
Accurate and objective charting is crucial. Sometimes, when it's been busy/you're tired, it's easy to go into a robot like mode and just start clicking. I've seen nurses chart on Foleys that weren't there, I've seen them document on wounds and then go on to chart their skin is intact, and I've even seen periods of time >3 hours where nothing was charted at all.
On the first page of the nursing notes, I like it when the nurse who did the initial assessment writes where the patient is from (home, NH's name, etc), how do they get around at home (ambulate, cane, walker), do they have relatives nearby that help them? Do they live alone? Do they need help with ADL's?
Its such a pain to call report for another nurse who is busy, and have the floor ask me "where are they coming from?" And here I am, furiously flipping through the chart because none of this is documented. Seems kinda silly, but I'd like to know that the patient is going to the proper room that they need (ie you don't want to have a confused patient in a room farthest away from the nurses station).
("85 y.o. male coming from home; lives alone in a duplex, A/0x3, ambulates without difficulty - steady gait; son visits often, no assistance with ADL's needed, appearance is well-kept, arrived in ED at 0845 today with c/o chest pain that resolved PTA.")
Tiger, that is a great example of what perfect charting is if you have maybe 3 patients. Who in the heck has the time to chart that precise, when you have 6 skilled patients on top of 8 other patients. (LTC). I am new and this is frustrating, because my dream is to chart like Tiger and I just do not have the time. Rhonda
I like charting that I can easily read without trying to quess what it says because of poor handwritting. I also appreciate nurses who actually put in a new nurses note when they use up the last one.
Specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.
because my dream is to chart like Tiger and I just do not have the time. Rhonda
Listen, while charting is important, patient care is the priority. I have met many a nurse who can chart flawlessly--that doesn't mean that his/her patient care was high quality. It sickens me to think that some days I take better care of my charts than I do my patients. They are the number one priority. They don't care how well you document their wound care or pain management if it means you didn't have the time to get them fresh water. I rarely go home at the end of the day patting myself on the back for doing such a good job with my charting. I'm not trying to say that documentation isn't important because it surely is. But, lets remember what the main goal of nursing is--taking care of people, not charts.
Listen, while charting is important, patient care is the priority. I have met many a nurse who can chart flawlessly--that doesn't mean that his/her patient care was high quality. It sickens me to think that some days I take better care of my charts than I do my patients. They are the number one priority. They don't care how well you document their wound care or pain management if it means you didn't have the time to get them fresh water. I rarely go home at the end of the day patting myself on the back for doing such a good job with my charting. I'm not trying to say that documentation isn't important because it surely is. But, lets remember what the main goal of nursing is--taking care of people, not charts.
I agree wholeheartedly! But remember...IF YOU DIDN'T CHART IT, YOU DIDN'T DO IT! Stinks but that's the world we live in....maybe we will have voice activated charting soon.
I would agree with the previous posts and add this: I really appreciate it when a nurse charts follow up things like "medication XYZ called into CVS pharmacy at 555-555-1212" or "Pt's daughter Susie notified of fall" or "Spoke with Susie at Home health XYZ, bed and w/c will be delivered between 1200-1400 tomorrow".
Also, when I endorse something that I wasn't able to complete on to the next shift, I wish that nurse would chart that is was completed or if not, what remains to be done. I try really hard to communicate with the oncoming nurse, they say they will follow up and then I come in the next morning and it appears nothing was done about it, no documentation, nothing in report. Then I waste precious time trying to find out if it was done!! Drives me nuts
I always write throughly when I first assess the patient and then 2 hourly document any changes if needs be. I am a day shift person and we dont computer chart so we have daily trifolds. I will check back on the previous days documentation if the patient doesnt fit the report from night staff-but a lot of the previous nursing charts rarely inform.
We are so diverse in our documentation. I firmly believe if we document the abnormal rather than the normal it highlights more
Her handwriting! It's so legible!! I envy anyone who can write so that any normal person can read it -- I've tried to improve my handwriting for years and have failed miserably!
I have very clear handwriting-but I do have a different way of documenting, I found this out the other day when the night staff told me they love reading my entries!!!!!!!!!!!!!!!!!!!!!
working in the ER - I know what I appreciate, especially when I'm assuming care for a patient:
1) documenting what is going on! Like what time a patient started contrast prep, they went for xray, CT, u/s, etc.
2) documenting how a patient presents to the ER and what EMS' story is and how they presented to them. What was done in the ER ( a nice note is always helpful).
3) DOCUMENTATION - and updating VS is always nice before I assume care! A good nurse will cross the t's and dot the i's prior to leaving the end of their shift, like making sure IV access is secure, bag isn't empty or blood backing into line. Finishing up your portion of things that were ordered HOURS ago and never done, just letting it fall to the next person (ex. an elderly woman, increased confusion and weakness and not obtaining a urine specimen b/c you didn't take a moment to do a straight cath)
4) Documenting what time you tried to call report (even if multiple times). It's tough tough tough to call report on a patient that you just took over care of and you know nothing about.
I think just doing your job to the best of your ability (and of course unless the poop hits the fan and you're unable to do anything!) is appreciated. A good honest effort is what I respect.
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MoopleRN
240 Posts
Accurate and objective charting is crucial. Sometimes, when it's been busy/you're tired, it's easy to go into a robot like mode and just start clicking. I've seen nurses chart on Foleys that weren't there, I've seen them document on wounds and then go on to chart their skin is intact, and I've even seen periods of time >3 hours where nothing was charted at all.
My rule of thumb when charting is:
Pt's condition when I entered the room.
What I did while I was there/how well tolerated.
Pt's condition when I left the room.