Current Charting
Current from google definitions means "belonging to the present time"; "happening" or "being used" or "done now."
Current charting in nursing means to be up to date. The patient may have changes from admission to admission (especially “frequent flyers”) even though their previous assessment and admission information is still there.
Situation:
A patient is admitted to your unit at the hospital. The patient tells you while doing his admission assessment that he was here only a few weeks ago. You begin documenting and realize all of his admission assessment is still there from the previous admission, and decide to copy and paste forward his most previous shift assessment to save you time. The last assessment reads as follows:
Neuro: A, A, O x4
EENT: WDL
Cardiac: WDL, BP WNL, on cardiac meds per MD order, s1,s2 heart sounds upon auscultation.
Respiratory: lung sounds clear bilaterally, 02 saturation WNL on room air.
GI: patient complaints of stomach cramping and bloating, LBM today (last bowel movement), no diarrhea, patient on Bentyl per MD order
GU: WDL
PSYCH: patient’s behavior appropriate for situation
Neurovascular: +2 edema to BLE (bilateral lower extremities), patient states they “have gotten better” Lasix per MD order.
CVL: 20G to right AC (antecubital, bend of the arm) removed per MD order for discharge.
During your initial assessment you find the patient is a,a,ox4. No problems or complaints noted with ears, eyes, nose, or throat. The patient is now running hypotensive and states his doctor told him to “stop taking my blood pressure meds.” The patient complains of SOB when walking short distances and requires 2L oxygen via nasal cannula to maintain oxygen saturation above 93%, and has crackles posteriorly to lungs. The patient has no complaints regarding bowels or urination. BS are active in all 4 quadrants. The patient states he “has not taken his Bentyl because he has not needed it.” The patient appears to be upset about having to be in the hospital after having been discharged so recently. He asks “is there anyway the doctor could order me something for nerves or to relax me?” The patient still has some mild swelling to BLE, but he states “my doctor told me not to take my Lasix since my blood pressure has been running so low.” The patient currently has no IV access.
What To Do: Pt. AAOX4. EENT: WDL, Pt is hypotensive (low blood pressure), states not taking Lasix, and BP meds per MD order. C/O SOB when ambulating short distances. O2 @ 2L per NC to maintain O2 Sats > 93%. Crackles auscultated to posterior lung fields bilaterally. +BS X 4 quadrants. GU: WDL, Pt appears anxious, will notify MD. No IV access.
What Not To Do: NEVER copy and paste the work of another. ALWAYS make sure your charting is CURRENT!
Current from google definitions means "belonging to the present time"; "happening" or "being used" or "done now."
Current charting in nursing means to be up to date. The patient may have changes from admission to admission (especially “frequent flyers”) even though their previous assessment and admission information is still there.
Situation:
A patient is admitted to your unit at the hospital. The patient tells you while doing his admission assessment that he was here only a few weeks ago. You begin documenting and realize all of his admission assessment is still there from the previous admission, and decide to copy and paste forward his most previous shift assessment to save you time. The last assessment reads as follows:
Neuro: A, A, O x4
EENT: WDL
Cardiac: WDL, BP WNL, on cardiac meds per MD order, s1,s2 heart sounds upon auscultation.
Respiratory: lung sounds clear bilaterally, 02 saturation WNL on room air.
GI: patient complaints of stomach cramping and bloating, LBM today (last bowel movement), no diarrhea, patient on Bentyl per MD order
GU: WDL
PSYCH: patient’s behavior appropriate for situation
Neurovascular: +2 edema to BLE (bilateral lower extremities), patient states they “have gotten better” Lasix per MD order.
CVL: 20G to right AC (antecubital, bend of the arm) removed per MD order for discharge.
During your initial assessment you find the patient is a,a,ox4. No problems or complaints noted with ears, eyes, nose, or throat. The patient is now running hypotensive and states his doctor told him to “stop taking my blood pressure meds.” The patient complains of SOB when walking short distances and requires 2L oxygen via nasal cannula to maintain oxygen saturation above 93%, and has crackles posteriorly to lungs. The patient has no complaints regarding bowels or urination. BS are active in all 4 quadrants. The patient states he “has not taken his Bentyl because he has not needed it.” The patient appears to be upset about having to be in the hospital after having been discharged so recently. He asks “is there anyway the doctor could order me something for nerves or to relax me?” The patient still has some mild swelling to BLE, but he states “my doctor told me not to take my Lasix since my blood pressure has been running so low.” The patient currently has no IV access.
What To Do: Pt. AAOX4. EENT: WDL, Pt is hypotensive (low blood pressure), states not taking Lasix, and BP meds per MD order. C/O SOB when ambulating short distances. O2 @ 2L per NC to maintain O2 Sats > 93%. Crackles auscultated to posterior lung fields bilaterally. +BS X 4 quadrants. GU: WDL, Pt appears anxious, will notify MD. No IV access.
- AAOX4 means awake, alert, oriented to person, place, time, situation.
- EENT means ears, eyes, nose, throat.
- WDL means within defined limits.
- BP means blood pressure.
- C/O complains of.
- SOB means shortness of breath.
- NC means nasal cannula.
- +BS means positive bowel sounds.
What Not To Do: NEVER copy and paste the work of another. ALWAYS make sure your charting is CURRENT!
Picture from: Flexchart; http://www.forerunsystems.com/products/flexhart-nursing/; 2014;
Web; accessed 13 Nov 2014.