CHARTING

Question 1

Lying supine. Resting with eyes closed. Respiration’s even and nonlabored. Familypresent at bedside

Question 2

Up with assist. PT at bedside to ambulate. Ambulated 50 feet via walker with 1x assist.No complaints voiced.

Question 3

BP 180/100, HR 85. Reported to Dr. Smith via telephone. Orders to administer Labetalol5 mg, q10 min, for a total of 20 mg. Goal of systolic pressure less than 160. (Note herethat I did not state that it was HIGH, simply stated the facts

Question 4

Dr. Smith at bedside to assess patient wound. No new orders at this time.

Question 5

Bed bath and linen changed offered. Patient refused.

Question 6

Anesthesia block performed to right shoulder by Dr. Smith. Tolerated well. Nocomplaints voiced

Question 7

O2 saturation 88% on 4L NC. Instructed to turn, cough, deep breathe. Incentivespirometry performed 10x. Met goal of 2000. Saturation’s increased to 92%

Question 8

O2 saturation 89% on 3L NC after performed incentive spirometry. Dr. Smith at bedsideto evaluate. Orders to administer nebulizer treatment

Question 9

Complains of chest pain. States “feels really tight”. Normal sinus rhythm noted onmonitor. HR 96. Dr. Smith notified via telephone. Orders to obtain 12 lead EKG

Question 10

Belongings in room in couch in blue duffel bag. Glasses and cell phone within reach onbedside table.

Question 11

There is no need to continually use the word “patient” as the entire note is aboutthe patient

Question 12

Most facilities use electronic forms of charting so when you input a note yoursignature automatically populates. Keep in mind if you were to write ahandwritten note (which you will complete on your clinical paperwork) you mustdraw a line to the end of the page and add your full signature and title. Examplebelow.Up with assist. PT at bedside to ambulate. Ambulated 50 feet via walker with 1x assist. Nocomplaints voiced.___________________________________________Hannah Mottel, RN

Question 13

Do not duplicate charting. You will not be adding information into a note that hasalready been charted in your assessment area or elsewhere. Think of a nursingnote as “extra” information that needs to be short, sweet, and strictly contain thefacts.

Question 14

Always use full names and titles when referring to other disciplines. Ex. “Reportgiven to Brittany, RN.”…..You must add Brittany Smith, RN. (There couldpotentially be 5 Brittany’s present on the unit you are on

Question 15

If you are composing a handwritten nursing note, make sure you add the date andtime (that the task occurred) at the top. The EHR will automatically input this foryou

Question 16

Simply state the FACTS. This is not an area where you will be writingparagraphs, think “short and sweet”

Question 17

ORAL

Answer 17

the date and time oral care was provided or observed
 the patient’s level of participation in oral care
 the condition of the patient’s gums, mucous membranes, and teeth and any abnormalfindings (pain, bleeding, sores)
 the patient’s response to oral care
 patient and family teaching done

Question 18

bathing

Answer 18

the date and time the bath was given
 the type of bath given (partial, complete, therapeutic)
 the patient’s level of participation the condition of the patient’s skin and any abnormal findings
 any interventions implemented for the skin
 the patient’s response to the bath
 patient and family teaching done

Question 19

perineal care

Answer 19

the date and time perineal care was provided
 the patient’s level of participation
 the condition of the patient’s perineum and any abnormal findings
 any odor or discharge (color, consistency, amount)
 the patient’s response to perineal care
 patient and family teaching done

Question 20

hair and scalp care

Answer 20

the date and time hair and scalp care was provided
 the condition of the patient’s hair and scalp and any abnormalities
 any infestations and treatment that was initiated
 the patient’s response to hair care
 patient and family teaching done

Question 21

shaving

Answer 21

the date and time shaving was done
 the patient’s level of participation
 the condition of the skin on the patient’s face before and after shaving
 any unusual bleeding caused by shaving
 interventions implemented to stop the bleeding
 the patient’s response to shaving
 patient and family teaching done

Question 22

eye care

Answer 22

the date and time eye care was provided
 the condition of the patient’s eyes and surrounding area and any abnormal findings
 the condition of the eye socket if the patient has a prosthetic eye
 the patient’s response to eye care
 referral to an ophthalmologist if necessary
 patient and family teaching done

Question 23

nail and foot care

Answer 23

the date and time nail and foot care was provided
 the condition of the patient’s nails and feet and any abnormal findings
 the patient’s response to nail and foot care
 referral to a podiatrist if necessary
 patient and family teaching done

Question 24

evening care

Answer 24

the date and time evening care was provided
 the type of care given (oral hygiene, back rub)
 any medications given to help with sleeping
 the patient’s response to evening care
 patient and family teaching done