Published Apr 11, 2006
48 members have participated
SouthernLPN2RN, MSN, RN, APRN, NP
489 Posts
Where do you keep your nurses notes? We keep ours on the pt chart, but I miss the way I did it on my old unit where it was part of the bedside chart.
jgwe4e
29 Posts
We keep ours in a small nursing chart which is filed beside the large pt chart at the nurses station. It normally has 2-3 days of flow sheets, med sheets, and the care plans.
NurseBettyTexas
11 Posts
Our hospital has computerized charting and all our notes are done on the computer
danigirl58
168 Posts
well the vital signs are kept on a sheet out side of the pt room, then of course we have other notes in the pt's charts and then the meds are kept in the mar binder....... having all these places to look in can be kind of interesting at times if there are med/nursing students and dr's with any one of them. sometimes i run around and actually call for my chart/mar
Spidey's mom, ADN, BSN, RN
11,305 Posts
In the chart under "Nurse's Notes".
steph
perfectbluebuildings, BSN, RN
1,016 Posts
On the computer, which is where a majority of our charting goes including assessments, etc.- but then, they are printed out each day and added to the chart, but not charted on the chart if that makes sense
SmilingBluEyes
20,964 Posts
Of course, we are computerized so the nurses' narratives go in the puter. but the vitals are charted on a sep vital signs sheet for dr, in the chart. all stays in the chart. I cannot see having nurses' notes anyplace else, really. That is what kardexes and clipboards were always for ---at least for me.
suebird3
4,007 Posts
my boss came up with a 72 hour charting sheet. used for admits/re-admits/falls/behaviours. when finished with the charting, sheets placed in the chart.
i tell ya, these sheets sure beat pulling up to 15/20 charts at a time....more if you're the lone nurse on 11-7's!
suebird
JAHJF
88 Posts
We have computerized charting and then when a pt is transferred from L&D to the MBU all the notes, etc are printed out and placed on the chart.
suebella
14 Posts
We do all our charting on the computer. I didn't think I would like it at first, but now it would be hard to go back to paper charting.