What do I chart on the Nursing notes???

[closatssl1]

Yes, I am a new grad and just started working on a Med surg floor. During my years in school I didn't get much experience when it came to charting nursing notes. I am having a little problem knowing not only What to chart but also how to word my nursing notes. I understand that charting is different for every patient depending on their assessment and condition. Nevertheless, nurses develop theor own system of charting and I was wondering if there are any nurses out there that would share their own style of charting and/or are there any books out there that will help me with charting nurses notes on the flowsheets. (e.g. Received patient on bed. Patient swhows no apparent signs of distress and no complaints of pain at this time...) something to this nature.

[meownsmile, BSN, RN]

It depends on what your note is for. Is it to address the care plan, is it a note to acknowledge you recieved a patient from ER or PACU? Is it a note regarding a call to the physician? It really makes a big difference as to how much and what you would chart.

A note at recieving a patient would include everything regarding the patient status at the time. Foley, IV sites, fluids running, pain level, any distress, oxygen in place, vitals, any dressings incisions or sutures and their condition and status of any drainage, if family is present.

A care plan note technically only needs to address the plan of care. However, after addressing the plan, i always include kind of a patient status and small summary of the patients day including ambulation, how they tolerated PO, voiding, vitals, and address if safety measures are in place such as bed in low position, call light within reach and then i comment regarding any injuries or lack of for that shift. I may include whether a dressing change was completed, how well the patients mobility is whether they need 1 or 2 for assist to transfer, etc.