Thank you so much for sharing. I'm a 1st year telemetry nurse and I've always struggled with documentation (how much to chart, how little to chart to protect myself and to show proof care was provided). This really helped to fill in the gaps. Thanks so much for the refresher! xoxo
+Andrea Rackley That's awesome! Thanks for letting me know this helps. I appreciate it a lot. I do hope you find more of my videos helpful. :) See you! -xoxo
thank you thank you thank you! !!Most important tip DON'T SHOW EMOTION! !I'm a new nurse, I had been having some issues with documenting, I show "too much emotion"at least based off what you've just shown me. I feel like now I definitely have a chance of improving , thank you! !!please put out more of these! !! I'll be watching! !
keep them coming! documentation has always been a stressful thing. it helps to see how others do it. any tips for having to hand write out a nursing assessment when it is not computerized?
Thank you so much for posting all these videos! I am a recent grad with a new job on a tele floor and find your videos so motivational and inspiring! Love them! :-)
Thanks a bunch. Very Helpful. I'm working on telemetry . I'm a new grad whos still in orientation. I document so much extra information. This will help me . Also your channel was helpful in assisting me to prepare for NCLEX. I passed on my first attempt on February 22,2016!!!
+CaShaldra Robinson That's awesome! I'm thrilled to hear your experience. Thanks for sharing. It means a lot. I wish you all the best at work. Have a great day. -xoxo
Omg !!! I just love everyone of your videos so far, it seems that each video builds confidence. Thank you so much for this video because I definitely need to work on my time management and more videos like this one will surely help me to be more time efficient!
really liked it. we are actually encouraged not to abbreviate though somethings we do of course. we have the ability to create shortcuts though like you can make .HFR = High Falls Risk , so that will be put in your note if you type .HFR. I have actually never heard of that being abbreviated but most of the ones you put we do use.
I agree, I do not believe you can make up your own abbreviations. Doesn't it have to approved legally, I do not remember using v/u... as verbally understood , unless I need a update in abbreviated medical terminology myself.
Continue to monitor is not bad, it is just incomplete. Since nursing interventions must be observable, measurable and specific you should always state how/when you will continue to monitor. Ie: will reassess patient in 2 hours. Will continue to monitor patient's respiratory status every 4 hours. Will continue to monitor urinary output every hour, etc.
Please note, CAPS lock throughout a nurse's notes is discouraged. This comes across as aggressive and can be confusing when using periods for abbreviations and sentence breaks all in one note. For example: THE PT. STATES "I DO NOT FEEL DISCHARGE IS APPROPRIATE UNTIL I SEE THE MD." PROMPTING RN TO HOLD D/C. MD. NOTIFIED REGARDING D/C CONCERNS. First, by using CAPS it appears the patient is upset and yelling. In turn, this patient may be completely calm and simply voicing a further concern. Second, when reading this sentence, it can be difficult to hear the nurse's tone and inflections when the breaks between sentences is not as evident as it would be with capitalizing the first word of each new sentence. For all nurses out there, be very careful using the amount of abbreviations shown here in this video. Although, abbreviations can making charting faster, you must know what is accepted for legal documentation. "HRF" was interrupted here as "high risk for falls", yet a Google search turned up "HRF" to mean "Health related facility", "heart rate fluctuations", "histamine-releasing factor", "homologous restriction factor", "human readable format". When in doubt, write it out; leaves little room for misinterpretation.
Hey Caroline! Here in Australialand we only abbreviate as per hospital policy + guideline. Only if we could abbreviate as much as you guys :) where I work in ICU we also document head to toe assessments e.g. CNS, CVS, RESP, GIT, RENAL, & SKIN or ABCDEFGHI format each shift on top of cares provided. Thank you for the videos!!!
ehhssh That is so interesting! Thank you so much for sharing! I love hearing how nursing varies from country to country!! Looking forward to hearing from you again very soon!! xoxo - Caroline
hi, i just started watching your videos last night and I find it to be really helpful. I am a new nurse and I would like to be a succesful when it comes to charting a patient.
Pam Todd Oh wow!! That is so awesome!! Congratulations! Thank you so much for letting me know & also that the videos helped you! By the way (in addition to the ones above :) please let me know the types of video you want/need as a new graduate! I get tons of request from students, but I still want to make sure I cover topics relevant to Real Nurses (RN's) :D Keep in touch love!! xoxo - Caroline
Thank you for making this video. i go to a technical school and my teacher has shown us how to document. she told us that when you document you have to make a line and not leave spaces because someone could go back and write something annd get in you trouble
Richard Garcia Hi Richard! It's good to see you here again. Thank you very much for letting me know.It means a lot. Looking forward on seeing you here again. -xoxo
The link for dropbox says it's broken. Is there any way you can repost the link? I know this video was a long time ago but the information was really helpful! Thank you!
About to start working as a hospital nurse and I am super excited. Thank you for sharing this information because I understand that time management will be a tough hurdle. Please continue your tips and ideas on this subject. Also, do you carry around a template to write quick notes such as intake/output, bp, hr etc....?
BlushnBlue Awe awesome! Thank you so much for letting me know!! I usually document things like I&o asap, for example, If I'm floating to the unit & we need to do Q1 or Q2 hr. I&O.. because the computer can calculate it for you :) Then, when I need to know the I&O - if I don't remember, I can look it up & there it is :) The same goes to the BP & HR.... but if it is super abnormal.... I will probably make a sticky not about it, because the Dr. probably needs to know.... here is a video describing the kind or type of sticky note I would create: ru-vid.com/video/%D0%B2%D0%B8%D0%B4%D0%B5%D0%BE-PN1x4GiAzVk.html Please let me know any video request you have as a new graduate!! And again! CONGRATS!!!! xoxo - Caroline
great notes and tips! no matter how much i hear it I just can't seem to grasp cardiac nursing r/t preload and C.O. and how the medications affect it. can you offer any visuals in a future video
POINT OF CARE CHARTING! Another huge tip I use is to make use of the comment box section of the flow sheet. In this section, you can quickly document (in live time) anything and everything that's going on. For example, just quick notes while you're rounding, such as, "pt in bed watching TV, no needs" "pt sleeping w/o signs of distress" "pt left unit to go downstairs" "pt returned to unit from xray" "Dr. Smith at bedside performing I&D". This way, you know EXACTLY what time pt was last seen (if they go AMA or elope), or last time they were seen conscious/breathing if you happen to walk in their room and you need to call a code blue. I use this method of live charting all the time. It's a quick way to document even when there's a million things going on during your shift. You can always write a more detailed SBAR or DAR note later, but I also prefer to write these notes as soon as the events (new orders, assessments, interventions, etc) as they happen because the information is still fresh in my mind and I'm less likely to forget to document anything. Point-of-care charting also saves a lot of time. When you're super busy, it's easy to push the documentation to the end of the shift, but when you do it live/point of care, not only is your charting more accurate, but you also save time because you don't have to think back to everything that happened in the last 8-12hrs.
I like your video and I think it helps give new nurses a good idea of how to save some time, but new nurses also need to be aware of a few points that should be stated. First if you use an abbr. in a note, you better be able to remember what that abbreviation is 30 years from now when someone questions it. Consistency is the key. Second, do not use abbreviations that are not commonly used. You are not the only one reading your note, other people need to know what you saw and what you did since you are the primary observer of the patient. Do not diagnose the patient in your notes. Learn what the line is between assessment and diagnosis. The RN is not allowed to diagnose. And sorry Caroline, their are only two things I have to disagree with. First, why are you putting patient or pt in your note? Pt off floor W/C to CT @1330 is the same thing as off floor W/C to CT @1330. Or patient states..... is the same thing as states... It should be understood that you are documenting on your patient. So in the interest of saving time, don't bother with putting pt in your note unless it doesn't make any sense. Second... as a director of nursing I tear people up for putting will continue to monitor. If you have a habit of putting will continue to monitor in your notes you are asking for trouble. Lets say you forget to put will continue to monitor in one of your notes. Does that mean you didn't monitor the patient after that? Even if you always put will continue to monitor then I ask you, isn't that your job anyway? Its like documenting in my note "will continue to do my job." My advise, avoid it. George Harrison III MSN, APRN, FNP-BC.
I sometimes write will continue to monitor. I always put in the beginning the specific problem that I am documenting/ monitoring. So it makes perfect sense to write at the end “will continue to monitor “. There’s nothing wrong with that. You’re too picky
It’s not LIKE writing will continue to do my job. That would be “will continue to do my job” as an Rn you do more than just monitoring patients ! You know that! Don’t be ridiculous. Don’t be a know it all it’s annoying !
This is great, abbreviations seem to vary by states. I worked in Oregon as a nurse and was only allowed to chart from a list of approved abbreviations. Ohio seems different also but I have not seen a list of approved abbreviations, everyone seems to chart differently so I’m trying to keep up.
Megan Johnson Awe good!!! So glad to hear that you wanted to see this!! Enjoy the link & remember to let me know which videos you want to see more information on! xoxo - Caroline
I have many questions. Thanks though for creating this youtube. One of my question is do you think that someone whom English is their second language can do BSN? I graduated high school here, and I have my two years degree, but that is not it. I want to do Nursing. I applied the program and I got it in the program this Fall 2016. But there is something that is holding me back. and that is fear. I am afraid of reading, and writing the essays. What do you recommend me?
Thank you so much for sharing and for the advice!!! I was hoping to use the link you provided to the documentation examples, and I know this video is from 2015 but the dropbox link no longer works unfortunately :S
dddemarino Awe yay!! Thank you so much for letting me know that you liked it!! It means a lot :) Looking forward to seeing you on here again very soon!! Lots of love, - Caroline
Kelvin Caraballo Hi Kelvin! I honestly do not know enough about being an x-ray tech. But, I can say that nursing is considered a very substantial degree, where I think most people view x-ray technician as kind of just a license... Also, I'm not sure about x-ray tech... But with a nursing degree, there is a lot of potential for growth... ie. different opportunities in hospitals or offices, also higher education ie. nurse practitioner, nurse anesthetist, nurse educator... and more! I hope this helps you make your decision! Take care! xoxo - Caroline
Hi Pam! Thank you so much for letting me know that you also think an SBAR video would be helpful! And the accent issue is definitely an issue!! I will create a video on that as well! If you think of any other topics that you would like to see, please let me know!! Looking forward to seeing you on here again very soon!! xoxo - Caroline
great notes and tips! no matter how much i hear it I just can't seem to grasp cardiac nursing r/t preload and C.O. and how the medications affect it. can you offer any visuals in a future video