What does your school use for documentation?

verene, MSN · Dec 4, 2018

What kind of documentation? For clinical care plans during clinical we used paper documentation. For care provided during clinical we used the clinical site EHR. For hour logs either excel or a program called Typhon.

Specific items included in documentation varied based on purpose of documentation and needs of setting / patient population.

roenthatcher · Dec 4, 2018

Thanks for your reply verene. I kept my question pretty broad because I know schools can be very different in what they require their students to do. I was not totally sure what to ask about. For instance, you are the first person that I have heard of requiring hour logging. The differences are interesting. My school has a three page paper document. Page 1 is includes pertinent patient Hx, physical assessment, Morse fall scale, Braden skin assessment, vitals, pain scale, and questions about what is the most important thing to assess in this patient. Page 2 is choosing three problems and goals, and then space for a narrative. Page 3 is a care map that is supposed to include problems, interventions, labs, meds, and where they fit and how they connect. We do that for each patient.

That is all we do. Our sites will not allow us to document in their EHR, and we don't log hours or anything else. My last semester we will have a preceptorship, and the documentation will be different there.

mindofmidwifery, ADN · Dec 4, 2018

We use the clinical site EHR for normal patient/patient care/med admin documentation i.e., assessments, hourly rounding, vitals, Braden/Morse assessments, line/drain/tube documentation etc. Aside from that, we have clinical paperwork due weekly that includes a care plan, head to toe assessment, and med sheet.