What should be included when Charting?

[Nursebabe2009]

I'm a new Registered Nurse with my first job at a Nursing Home. My problem is that the college I attended didn't focus on charting at all. My question is what should be included in the charting? Is there a system to follow when charting? Is there a place online that has a step by step process? Thank you for any help and Happy Easter.

[Nursebabe2009]

First, I would like to thank everyone who responded to my question. It is nice to know there are nurses who care and can help out. Second, would anyone happen to know a good book that deals with Charting? Is the Charting Made Incredibly Easy book something that would be informative? Are there any other books that may be beneficial? We don't have a lot of nurses at the site. The nurses who are there, tend to work long hours and have familes. Therefore it is impossible for them to review my chartings. Again I thank everyone for their value and informative information.

[marilynmom, LPN, NP]

You can't really be taught charting in school anyways. We went over the different types of charting, what to do chart, etc in school but real like charting is just so different.

Every place and every RN charts differently. Read other nurses charting--you will see that some chart badly and others are great charters. It took me a bit to get my charting down.

Don't forget to chart about safety. I think that is really important to chart. Especially in LTC.

[Magsulfate, BSN, RN]

Well,, is there an assessment sheet? If so, fill in the blanks. Different facilities chart differently so it's hard for us to tell you how to chart there.

If you have to write out your findings in the nurses notes,, just focus on the problems, like someone said earlier.

You could start out by saying... 0800-Assesment complete as noted, pt in bed, semi-fowlers position. Awake and smiling, verbally making needs known. No distress noted, Pt denies pain, denies SOB, Denies discomfort. Then go on to the problem or the procedure you performed.

Your facility may not want you to document each time you flushed a peg tube or the like. But you probably need to document any wound care dressing changed,, changes in a wound,,, .. stuff like that. If the patient has any edema,,, anything out of the ordinary.

I hope this helps a little.

[diane227, LPN, RN]

Everything. You should get with your manager or the most experienced nurse on your floor and go over your documentation forms in detail. When the patient arrives, it is important to do a complete physical exam so you can find any indication of decub ulcers. If they are not documented when the pts come in then someone will declare that it occurred at the hospital. Make sure you do a complete fall evaluation and place a bed alarm on if you think the patient is a fall risk. check your Iv sites often during your shift and chart what they look like. You can do a specific focus in your notes once you have done the exam. Your charting should be specific to the chief complaint. Example: if you have a patient who has had a total knee, you would want to eval the dressing, CMS, pain etc on a regular basis. Don't chart in general terms: no complaints, sleeping etc. It is useless. When you document something and make an error, one line through the error and your initials. If you forget to chart and have to do a late entry document it as such. If you have an incident occur NEVER MAKE REFERENCE TO THE FACT THAT AN INCIDENT REPORT WAS COMPLETED. This will make this report discoverable under the law. You might do well to get yourself a basic legal nursing book and read some kind of the cases that nurses have gotten in trouble for. It is very helpful. And remember, it is the little stuff that will get you in trouble, wrong med, IV infiltrations, falls, failure to turn or suction. There is just so much. And your charting will get better with time. . Diane

[Magsulfate, BSN, RN]

I have to disagree with you on charting if the patient is asleep, or if they deny discomfort. This is very important,, who knows if in two hours they may have a lot of discomfort,, in the notes it will show when it started, and that two hours ago they were resting with their eyes closed, or they denied pain and discomfort.

Also, the OP stated she is working in a nursing home. I don't think there will be any IV's there.

I do agree that she needs to talk with management or the charge nurse at the NH facility about the charting. Like I said earlier, charting varies widely from facility to facility and to NH.