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Information to Obtain During Report

Components of the Health History Support

Documentation & Charting Guidelines


DOCUMENTATION (CHARTING) GUIDELINES Think of your charting as a camera that takes the patient's picture. Organize Your Thoughts: What have I seen that relates to this problem? What have I done about it? What do I plan to do about it? How has my patient responded to what has been done? Build Your Planning On: Your initial assessment and further findings. Your identification of the patient's problems. Your patient care. General Guidelines: 1. Chart neatly, legibly, and in blue or black ink. 2. Be brief, concise, accurate, and complete. 3. Use good grammar, correct spelling, correct punctuation, and proper terminology. 4. Note the time of each entry; also include month, date, year at the beginning of the shift charting. 5. Use a new line for each "new" (timed) entry. Put an ink line through extra space on the line you are charting on if you haven't used the entire line. 6. DO NO ERASE. Draw a single line through an error, write "incorrect," "error," or "mistaken" entry over it and sign your initials (check agency procedure). 7. Never chart in advance of doing something; particularly do not chart medications before they are administered. 8. Include your signature and student designation (i.e., "S.N."). Use first initial and last name with that designation. 9. Leave out the word "Patient." If the meaning of the entry is ambiguous, use patient's name. 10. Use only those abbreviations accepted in your hospital (see the documentation manual). 11. Retain recopied pages in back of the chart (i.e., corrected graphic record). 12. Check on correct format for charting in your clinical facility. 13. Use flow sheets whenever possible--don't duplicate the information in the nurse's notes. 14. Use easily defined terms (i.e., "ate 75% of meal," rather than "ate well"). 15. Rather than "tolerated well," state outcome: tolerated without pain, without nausea, or without complaint. ("Well" means different things to each of us.)

Content to Include: Body Care: Type of bath, back care, skin care and assessment, mouth care, hair care, perineal care, position changes (most data goes on flow sheets). Intake: Diet, amount eaten, fluids (oral, NG, IV); IV site condition, type of fluid, equipment changed, complaints (use activity sheet, I & O sheet, IV flow sheet). Output: Emesis, B.M., wound drainage, urine, vaginal flow, perspiration; include amounts and appearance (I & O sheet, nurses's notes). Treatments: Time, type, duration, appearance of area treated, special equipment, specifics of procedures: how it is done, patient response. If left unit, time left and by which conveyance; time returned. ests: Laboratory specimens drawn, cultures, disposition of specimens, x-rays, sonograms, endoscopies, patient reaction, outcome if known, time left and returned to floor. Dressings: Appearance of incision or wound, smell, presence of drainage, and appearance, how redressed and by whom. Activity: Time, ambulation and distance, exercises performed, including leg and breathing postoperatively, ROM performed, physical therapy, condition of pressure points, repositioning and for how long, and patient responses to each. Oxygen: Time applied or amount changed, method of administration, safety precautions. Medications: Time, amount, route, response, any adverse reaction or side effects, omission or delay, evidence of expected action (PRN and STAT doses are charted on the medication administration record [MAR] as well as the nurse's notes). Sleep: Day or night, amount, interruptions, patient comments. Mental State: Mood, level of consciousness, general behavior (be objective). Preoperative Preparation: Teaching, physical preparation, time and by whom; patient questions. Special Conditions: Traction, cast, special equipment--time applied, condition of patient, circulation checks and findings, skin condition, smell. Vital Signs: Temperature, pulse, respirations, blood pressure; weight (on graphic record). Doctor's Visits: Examinations and treatments. Visitors: Who, how long, patient reaction. Feelings: What patient states regarding feelings, complaints, concerns. Physical Assessment: What you see, hear, smell, and feel: Auscultation of lungs, heart, bowel sounds, palpation of abdomen and pulses; inspection of skin, assessment of problem area in depth. Safety Factors: Side rails up or down, replaced after working with patient; warnings; restraints in place.


QUICK ASSESSMENT At the beginning of each shift, each patient should be assessed quickly. This is often done along with taking the vital signs. Initial Observation Is the patient breathing? Skin color Appearance Affect How is the patient feeling? Head Level of consciousness Appearance of eyes Ability to communicate Mentation status Vital Signs Temperature Pulse rate, rhythm Respiration rate, pattern, and depth Blood pressure, compare with previous readings Abdomen Shape Soft or hard Bowel sounds Appetite Last bowel movement Voiding status Extremities Normal movement Skin turgor and temperature Peripheral pulses Edema Tubes and Equipment Present Intravenous catheter: condition of site, fluid in progress, rate, additives Oxygen cannula: liter flow rate Pulse oximeter: intact probe; readings Nasogastric tube: suction setting; amount and character of drainage Urinary catheter: character and quantity of drainage Dressings: location, drains in place, wound suction devices; character and amount of wound drainage Traction: correct weight, body alignment, weights hanging free Pain Level Heart and Lung Assessment Depending on time available and condition of patient, auscultation of heart and lungs may be done on initial assessment of later in the shift.

GIVING REPORT Organize your thoughts using an outline format before you give report to the staff nurse assigned to your patient. State: Patient name and room number Condition of patient (any changes) and last vital signs, orientation Diagnostic tests/surgery undergone Treatments or procedures done (including bath)/accuchek on blood sugar, diet, activity, and how tolerated, restraints PRN medications given and effect Intake and output (if ordered) Amount left to count in IV Appearance of IV site Tubes in place and whether functioning properly; output Appearance of wounds and dressings in place Bowel sounds present or absent Whether patient had a bowel movement Voiding status Any abnormalities of heart or lung sounds Pain/comfort status Any patient concerns Be concise and professional. STAYING IN THE GOOD GRACES OF YOUR INSTRUCTOR Find out exactly what your instructor expects of you in the clinical area, and question any instruction you don't understand. Most instructors expect the following: Thorough preparation for the clinical experience Written work that is legible and neat A professional, crisp appearance A friendly, quiet, professional demeanor Sufficient sleep before the clinical experience Promptness for clinical and conference Active participation in clinical conference A quick report on your patients when approached during the shift Cooperative, team attitude with the staff Attentiveness to patient needs Appropriate, complete documentation Attentive listening and attention to instructions Seeking of skill experiences Taking responsibility for your own learning To find you in the patient's rooms when not charting, rather than sitting at the nurse's station You'll ask when you don't know how to do something, or whether it is permissible for you to do it To be notified immediately if something untoward happens or a mistake is made Eat breakfast before coming to clinical



Room number and bed designation: Date of admission and physician: Diagnoses: Current surgery or delivery & type: vaginal or C-section Gravida para Surgery or tests scheduled for next 24 hours: Vital sign schedule Neurologic signs schedule


Heat lamp TCDB


Dressing changes ROM Physical therapy

Whirlpool K-pad

Spirometer Heat/cold Type of bath: Activity: OOB Shower Assist BSC Bedrest PRN medications given last shift: Pain level: Dietary supplements Impairments: Vision BRP

Complete bedbath BRP with assistance

Abnormalities to report to physician: Diet: NPO I & O previous shift Insulin orders NG Flow rate Foley PRN Drains Continuous

Hearing Paresis


Accuchek blood sugar Tubes: Peg

Amputation (old/new) Mental status: Alert Confused Comatose

Oxygen: Cannula Mask

Medication changes: Problems: Concerns/need for order changes:

IV location, type & when inserted Solution hanging & amount left to count Solution to follow Equipment: Fetal monitor PCA SCD CPM Telemetry Traction/type Other

Needed teaching: Psychosocial status: Patient-family dynamics: Amount of assistance needed: