RNs: any advice on how I can improve my documentation and charting skills (I'!
Question: RNs: any advice on how I can improve my documentation and charting skills (I'm a student)!.!.!.!?
Are there unrealistic expectations, and random chart review audits!? Or does everything get done at the end of the day!? Has documentation ever worked for or against you in a litigation situation!? Www@Answer-Health@Com
Answers:
As an RN, you'll be charting constantly! At my job I have to chart EVERYTHING--but at the hospital, I believe, it's generally charting by exception (or if anything out of the ordinary happens)!. It's good to get the skills down, because, yes, there are random chart review audits (but don't worry so much about these)!. Just make sure you are being descriptive ("The pressure wound was X cm by X cm, located on the coccyx--serosanguneous drainage, no s/s of infection"), objective, making sure of the proper sequence of events--and how the situation was resolved (if on your shift)!.
In the hospital, try to chart as you go!.!.!.don't wait until the end, unless you absolutely have to! It might help to take a few notes as you go!.!.!.and have your instructor check your charting (they can probably give you a few pointers)---good luck!!! Www@Answer-Health@Com
In the hospital, try to chart as you go!.!.!.don't wait until the end, unless you absolutely have to! It might help to take a few notes as you go!.!.!.and have your instructor check your charting (they can probably give you a few pointers)---good luck!!! Www@Answer-Health@Com
If is not writing!.!.!.it didn't happened!. words of my instructor!.
so take it from there!.Www@Answer-Health@Com
so take it from there!.Www@Answer-Health@Com