Charting..... HELP!

I'm a "new" nurse and I feel like when I do chart it isn't "enough". What tips can you seasoned nurse give me. I feel like I'm not getting all my wording or I'm not charting "enough". Examples will be GREATLY appreciated. Thank you.
I have the same problem. I got a book on charting "charting the easy way", my facility has been in servicing us due some new changes in Medicare. I also try to follow a simple formula. Fir every thing that I chart I as myself, what did I see, what did I do about it, how did the patient react. When one nurse would write "c/o pain 8/10. PRN Dilaudid with effect" I would write, 4:30 c/o pain to L knee 8/10 when changing position in bed, facial grimacing noted, offered fluids, repositioned for comfort,PRN what ever, 5 pm pt states pain level manageable at 3/10, resting in bed,appears comfortable socializing with visitor.

Is this paper charting? I used to have the hardest time with my narrative bc some ppl would write an entire page. I always felt like I was double charting. Then I found out we were supposed to be charting by exception and there was nothing wrong with my method of describing the abnormal only. As far as pain assessment, we had a pain flow sheet so no need to do a narrative for that either. Thank goodness for computer charting now.

Quote from RNewbieIs this paper charting? I used to have the hardest time with my narrative bc some ppl would write an entire page. I always felt like I was double charting. Then I found out we were supposed to be charting by exception and there was nothing wrong with my method of describing the abnormal only. As far as pain assessment, we had a pain flow sheet so no need to do a narrative for that either. Thank goodness for computer charting now.

Everywhere I have ever worked, we ended up "double charting" or "triple charting." At my current hospital, we computer chart "by exception only," but it still seems we double chart stuff.

You bet other people (including physicians, at least the smart ones, if they know your notes will be worth spit) are reading them, people you never thought about.One of the very best compliments I ever rec'd from a physician was that he loved my documentation because he could really see what the patient looked like by reading it (bless you, John Mehigan, vascular surgeon, wherever you are). That is what you are aiming for. The best way to think about nursing documentation is to think first about what medical records are used for. Quick! How many things can you think of?1) Communications between staffers and disciplines2) Legal documentation of events, assessment, and care3) Supporting billing and insurance reimbursement (and that becomes your paycheck)4) Clinical research5) Education 6) Quality improvement/risk managementGold star if you can think of some more!The point is that you have to keep a lot more in mind when you write your notes and document your meds. All of those folks will be reading them sometime and counting on you to be accurate and descriptive. If your nursing documentation class had that in mind, by all means, take it to heart and use it every day. If it didn't, consider a creative writing class that teaches you how to see beyond the obvious and how to use good English to describe it for the reader. I can tell you at least one excellent doc, a lot of bean counters, medical and nursing researchers and academics, and many lawyers and nurse legal consultants will appreciate that.

Quote from GrnTeaYou bet other people (including physicians, at least the smart ones, if they know your notes will be worth spit) are reading them, people you never thought about. One of the very best compliments I ever rec'd from a physician was that he loved my documentation because he could really see what the patient looked like by reading it (bless you, John Mehigan, vascular surgeon, wherever you are). That is what you are aiming for. The best way to think about nursing documentation is to think first about what medical records are used for. Quick! How many things can you think of? 1) Communications between staffers and disciplines 2) Legal documentation of events, assessment, and care 3) Supporting billing and insurance reimbursement (and that becomes your paycheck) 4) Clinical research 5) Education 6) Quality improvement/risk management Gold star if you can think of some more! The point is that you have to keep a lot more in mind when you write your notes and document your meds. All of those folks will be reading them sometime and counting on you to be accurate and descriptive. If your nursing documentation class had that in mind, by all means, take it to heart and use it every day. If it didn't, consider a creative writing class that teaches you how to see beyond the obvious and how to use good English to describe it for the reader. I can tell you at least one excellent doc, a lot of bean counters, medical and nursing researchers and academics, and many lawyers and nurse legal consultants will appreciate that.

We use Meditech at my facility and there is next to no space to free-text very much at all. I think the free-text space for a pain assessment allows for 50 -100 characters max. We can link a note where we can free-text, which involves going to a completely separate section of the EMR. Then other staff need to specifically go to the notes section to read any notes. As a new nurse myself, I struggle with knowing how much or how little I should chart. It seems like with clicking boxes to chart by exception I don't have anywhere to document my observations and assessments in my own words. Blue

If Epic is being used to chart, whenever you document in the flow sheets, i.e vitals, pain, wounds, etc. you can add a note specifically related to that entry on the flow sheet, which would make an writing an extra nurse's note redundant. Work smarter, not harder.

Quote from Blue CatWe use Meditech at my facility and there is next to no space to free-text very much at all. I think the free-text space for a pain assessment allows for 50 -100 characters max. We can link a note where we can free-text, which involves going to a completely separate section of the EMR. Then other staff need to specifically go to the notes section to read any notes. As a new nurse myself, I struggle with knowing how much or how little I should chart. It seems like with clicking boxes to chart by exception I don't have anywhere to document my observations and assessments in my own words. Blue

I hate stupid checkboxes in our charting!!!Maybe this is bad but typically I just scroll by all the checkboxes and write a free text note. I don't know about any of you but I would rather write a note than check boxes, and I would rather read a note than stupid checkboxes.My charting is typically like this:"Pt resting quietly in bed throughout the shift. Wife at bedside all night. C/o "back ache" 8/10 gave PRN Tramadol at 0020, effective. PICC line to left upper arm has no s/sx infiltration or phlebitis. IV Zosyn infused without problem."I typically just try to chart about what happened throughout the shift but keep it short and sweet unless drama went down.Then something like this."When arrived at shift pt bed alarm went off several times. Agitated and trying to climb out of bed. Tolieted, drank fluids, repositioned for comfort. Continuing to climb out of bed. Due to safety concerns brought to nurses' station. Pt yelling "Get away!" and striking out at staff. At 2345 called on-call Dr. X and got order for one time dose of Seroquel and update primary MD in AM. Gave Seroquel which calmed pt by 0130. Spent rest of shift resting in bed with eyes closed."

The narrative note is where you can explain things that are not already noted in your assessment or elsewhere in the chart. For example, there is no reason to write in your narrative note that the patient is afebrile if his temperature has been documented as such throughout the shift. Some situations demand a long narrative note while others don't. For example, working in pedi home health now if I go in to give a child her scheduled weekly subq shot and she's been on this shot for years and tolerates it and neither her nor her parents have anything new to report, there's not much to write. If, on the other hand, I go in to a home (like I did yesterday) and discover that the child's mother has not administered his meds in 2 days because she claims that the pharmacy didn't have the supply in/had to compound them but then the pharmacy says that they aren't working on any meds for him and he's had a supply sitting there ready for 5 days and that she already picked up the medication she claims they didn't have 5 days ago but somehow she still doesn't have it in the home because she sent "everything she had" to the child's medical daycare which she keeps him home from 2-3 days/week and he doesn't attend on the weekends anyway, there's a book of a narrative note to write.

I remember being told many years ago that the word "appears" should never be found in a patient note. State the facts. Rather than saying appears to be comfortable, state the facts, i.e.: resting in bed, eyes closed, reading, no facial grimacing etc......