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??
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
also good to note who is in room with patient, 3 females, 1 male visitor - also note belongings in room and if they go to the floor with a patient. Note if visitors left with belongings - glasses, dentures, that kind of thing.
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
NO KIDDING about the I/O's issue!!!!!! If they're receiving IV fluids and have a foley.... address it!!!!!
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.
eeewwwwww sounds like paper charting!!!!!! aggghghghghggggggggg!!!!!!!!!!!!!1
MassED, BSN, RN
2,636 Posts
also good to note who is in room with patient, 3 females, 1 male visitor - also note belongings in room and if they go to the floor with a patient. Note if visitors left with belongings - glasses, dentures, that kind of thing.