Nothing to chart / document

Hi folks,

I'm a little ashamed to open this topic but I really need help.

As a student and when I began my practice as a nurse, we usually do traditional charting which is sort of a narrative charting which describes what we did for the patient.

Recently though we have adopted the FDAR method and whilst it's favorable and good, I'm running out of ideas on what to write in my patient's chart. I am aware that health teachings maybe used as part of FDAR however, given that the patient had been staying too long in the hospital (11 days) just to complete an antibiotic therapy that started on day 5, I'm running out of focus and my charting for most patient appears like a ditto from the earlier shifts (we have 3 shifts a day).

I must admit my time management skills aren't very polished given that the n ratio has bulged because of the outbreak of Dengue Haemorrhagic Fever. I tried to look into the labs but honestly, I am finding it difficult to justify the needs of some patient to be remaining in the hospital. I tried instituting bleeding precautions because of the low platelet count but I still find myself at a loss the next day when I handle the same patient with a higher but still below normal platelet count.

Any suggestions?

Thanks,

- Josh
School -vs- realityDo precisely what it is you are told to do by your instructors. If they want you to over-analyze everything, then do it.However, here's a little side homework for you.Take a close look at what the experienced floor nurses are charting. Remove all of the redundant nonsense that is already charted elsewhere, and you are left with the basics of what should be charted in narrative.

jmolina23--I'm having the exact opposite problem--trying to transition from nurse to student. I have to stop and think, "ok. it's work so chart short and sweet (our NN are basically a check off with a narrative for anything out of the ordinary)" or "it's school so write a novel about the pt". You'll get the hang of it soon.

"Do precisely what it is you are told to do by your instructors. If they want you to over-analyze everything, then do it."I don't believe that OP is a student...she has already started practicing as a nurse.OP, I am not familiar with the FDAR....what type of charting is it?

Quote from roser13"Do precisely what it is you are told to do by your instructors. If they want you to over-analyze everything, then do it."I don't believe that OP is a student...she has already started practicing as a nurse.OP, I am not familiar with the FDAR....what type of charting is it?

look at the physician's notes. They have to justify the patient's existance too.Ask the case manager. They are usually the ones doing utilization review and can tell you the rationales.

OK Thanks guys, I'll try to polish up my charting and work my way until I remove the redundancies.