New grad here, I'm struggling with charting, like how to word things properly. We didn't go over this while I was in school. Any tips?
August 6th, 2023
Keep it simple and factual. I do charting by exception, meaning I chart detail for only systems or behaviors, etc that are not in normal limits. For my progress note I do a brief statement/overview of the shift. A& O x __. Pain rated _ of _ managed with X intervention(s). Lungs including use of o2, heart, bowels, bladder, skin (wound), peripheral pulses, etc. Anything that I particularly want paid attention to I use a separate paragraph, i.e. Of note: these labs, these observations, increased pain... whatever I want the doc to see. As for wording, use medical language. Remember your audience is the doctors and fellow nurses. Hope that helps.