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Nursing Documentation Tips! 

EmpoweRN
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14 окт 2024

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Комментарии : 124   
@Cynthia_54x
@Cynthia_54x 6 лет назад
Most hospitals have approved abbreviations and those are the only ones which can be used. You cannot create your own abbreviations and put in a chart.
@andrearackley7508
@andrearackley7508 8 лет назад
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
@empowern
@empowern 8 лет назад
+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
@karenkuwahara4619
@karenkuwahara4619 8 лет назад
I wouldn't say "appears" in documentation. That is subjective. Use objective statements like "pt no longer exhibiting signs and symptoms of....."
@lylyicing
@lylyicing 8 лет назад
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! !
@tinaortiz9685
@tinaortiz9685 9 лет назад
This was very good and very helpful for us nursing student, thanks a bunch Caroline!
@empowern
@empowern 9 лет назад
Tina Ortiz Hi Tina! Thanks so much for letting me know!! So glad you liked it! xoxo - Caroline
@brookelynn14
@brookelynn14 8 лет назад
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?
@DianaJimenezMUA
@DianaJimenezMUA 8 лет назад
Can you do more of these videos please!! truly helpful, new RN here. lol
@nursenzi
@nursenzi 4 года назад
I agree ☝🏾
@katherine3324
@katherine3324 9 лет назад
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! :-)
@empowern
@empowern 9 лет назад
kathryn overton Ayee that's sweet! Thanks a lot for letting me know. It means a lot. Keep posted for more of these videos. see yah. -xoxo
@cashaldrarobinson3579
@cashaldrarobinson3579 8 лет назад
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!!!
@empowern
@empowern 8 лет назад
+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
@angelawiggins5377
@angelawiggins5377 6 лет назад
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!
@Stacyann_1
@Stacyann_1 9 лет назад
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.
@doogieRN1
@doogieRN1 9 лет назад
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.
@wenchypoo
@wenchypoo 8 лет назад
In the UK, the Nursing and Midwifery Council advise against abbreviations too. They are used all the time in verbal communication though.
@jugy4656
@jugy4656 2 года назад
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.
@ErikaEHE
@ErikaEHE 5 лет назад
I just found this video & I wanted to say thank you for all of your helpful tips👍
@Carahie919
@Carahie919 4 года назад
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.
@ehhssh
@ehhssh 9 лет назад
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!!!
@empowern
@empowern 9 лет назад
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
@kakefyll
@kakefyll 6 лет назад
Abbreviations seem to be a sure fire way for newbies to misunderstand things though...
@williamewing7124
@williamewing7124 8 лет назад
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.
@pamtodd6143
@pamtodd6143 9 лет назад
I've been working for 6 weeks now and passed my boards in an RN still in orientation thank you for all your help
@empowern
@empowern 9 лет назад
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
@erikamartinez4788
@erikamartinez4788 8 лет назад
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
@empowern
@empowern 8 лет назад
+Erika Martinez Absolutely! That's true :)
@rgvmarciano
@rgvmarciano 9 лет назад
Caroline, thanks for sharing! These tips are always a blessing.
@empowern
@empowern 9 лет назад
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
@TheAmber1030
@TheAmber1030 5 лет назад
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!
@BlushnBlue
@BlushnBlue 9 лет назад
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....?
@empowern
@empowern 9 лет назад
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
@MartFinds
@MartFinds 8 лет назад
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
@erikamartinez4788
@erikamartinez4788 8 лет назад
i have learned a lot from her and i have also learned a lot from you too, you are very intelligent and charming blessings to you and your family
@empowern
@empowern 8 лет назад
+Erika Martinez Awww you're so sweet! Thank you!! I'm sure you're a blessing to everyone too. -xoxo
@Randimal762
@Randimal762 8 лет назад
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.
@gmax1267
@gmax1267 8 лет назад
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.
@Sarah-bn1hg
@Sarah-bn1hg 4 года назад
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
@Sarah-bn1hg
@Sarah-bn1hg 4 года назад
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 !
@leahenry8044
@leahenry8044 6 лет назад
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.
@wehttamak
@wehttamak 7 лет назад
would love more documentation tips ...... system assessment when taking over a patient ... thanks for the tips
@zahraaalhaieri5091
@zahraaalhaieri5091 9 лет назад
That was such a helpful video. I think you're so intelligent Caroline.
@empowern
@empowern 9 лет назад
Rose H Thank you so much Rose!! The feeling is mutual ;) xoxo - Caroline
@emersonarchuleta
@emersonarchuleta 9 лет назад
Thanks for posting this one. Very helpful as always!
@empowern
@empowern 9 лет назад
emersonarchuleta You are so welcome love! Thanks for letting me know it helped. See ya! -xoxo
@mnj6773
@mnj6773 9 лет назад
I'm so glad you did this video & thank you so much for the link with the documentation tips link!! :-)
@empowern
@empowern 9 лет назад
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
@SLV0707
@SLV0707 7 лет назад
Thank you for uploading. Please more videos about documentation. Btw, the dropbox link is not working.
@methusellahparnaso4958
@methusellahparnaso4958 9 лет назад
Thank you so much for another great video! I hope you can make more videos in documentation! Thanks!
@empowern
@empowern 9 лет назад
Methusellah Parnaso Thanks love! For sure!! so keep posted. See yah! -xoxo
@mikeyanatomy
@mikeyanatomy 7 лет назад
Thank you for your examples!!
@empowern
@empowern 7 лет назад
+mikeyanatomy Your welcome!
@Selene0017
@Selene0017 9 лет назад
Super helpful! Thank you very much
@empowern
@empowern 9 лет назад
Selene0017 Awe yay!! Thanks so much for letting me know that you liked it! See you soon! xoxo - Caroline
@aiiyiabear2414
@aiiyiabear2414 8 лет назад
You're my inspiration and motivation to keep being strong in nursing school! Thank you
@MansonxXxAddiction
@MansonxXxAddiction 8 лет назад
Thank you :) practical assessment including documentation on friday, great tips that i will remember to incorporate!
@mikachavez6118
@mikachavez6118 5 лет назад
I have been reading nursing notes and EHR and it was in ALL CAPS. Is that a standard? Should it really be in capital letters?
@belbes01
@belbes01 8 лет назад
amazing nursing documentation tips. thank you so much it help me on my nursing documentation.
@aminazahra2011
@aminazahra2011 8 лет назад
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?
@puzz88
@puzz88 5 лет назад
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
@natalie-kn9fj
@natalie-kn9fj 7 лет назад
Thank you so much for this video. Very helpful
@annaleerose8620
@annaleerose8620 9 лет назад
Very informative, please post more like this.
@empowern
@empowern 9 лет назад
annalee rose Hi Annalee! I will definitely have some more coming. Keep posted. See ya.. -xoxo
@donnalockett7532
@donnalockett7532 7 лет назад
How often should I document on my patients?
@Ferouzah
@Ferouzah 9 лет назад
Excellent video Caroline! I know it will put this info to good use when I'm out in the real world. Thank you so much!
@empowern
@empowern 9 лет назад
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
@dorothydavis1974
@dorothydavis1974 7 лет назад
dddemarino i
@steffacation
@steffacation 9 лет назад
Great video idea! Thanks for all the tips!
@empowern
@empowern 9 лет назад
Steffa Dee Hi Steffa!! Awesome! Thank you so much for letting me know!! It means a lot :) xoxo - Caroline
@genevievemiranda5185
@genevievemiranda5185 Год назад
Best video yet
@kevin18887
@kevin18887 9 лет назад
What do you think of a career as an x-Ray tech? I don't know if I should do x-Ray tech or nursing : /
@empowern
@empowern 9 лет назад
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
@tarah58
@tarah58 8 лет назад
can i use the documenting skills as an lvn/lpn also?
@lbredikhin5
@lbredikhin5 5 лет назад
Thank you! I have trouble with skin documentation... Any tips?
@dancassidy7471
@dancassidy7471 3 года назад
As M/B instead of ad evidenced by ..blessing!
@sally9805
@sally9805 4 года назад
All those abbreviations when you just been told never use abbreviations or acronyms unless it's okay with your hospital.
@cherrysantos96
@cherrysantos96 4 года назад
Good thing we sont abbreviate in my workplace. Thank God coz that would be stressful to know what others' made up abbreviations
@pamtodd6143
@pamtodd6143 9 лет назад
SBAR definitely and do you deal with a lot of docs with hard to understand accents? Any advice
@empowern
@empowern 9 лет назад
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
@alih3553
@alih3553 9 лет назад
***** I vote for a SBAR vid :) great idea!
@nannzarzarkyi6985
@nannzarzarkyi6985 5 лет назад
looking forward another daily report.
@NurseBass
@NurseBass 9 лет назад
Haha, for a very split second you were like "What's the "R" in "SBAR" stand for again?" :p Great video Caroline!
@mairn2522
@mairn2522 9 лет назад
Recommendation
@jamie50308
@jamie50308 8 лет назад
Great tips/advice!
@sukeertyacharya6436
@sukeertyacharya6436 6 лет назад
which one is the standard tool for nursing documentation ?
@2012foreverneo
@2012foreverneo 8 лет назад
Having to write my first Nursing Notes for Fundamentals class and this video helped me tremendously!!! Thank you thank you thank you!!!!!!! :)
@empowern
@empowern 8 лет назад
+Kevin Powley You are so welcome! I'm glad to know it helped. It means a lot. Can't wait to hear from you soon. -xoxo
@NurseMurse
@NurseMurse 9 лет назад
I found this video very, very helpful! Also I was late to getting in your inbox. Ttys!
@missionscommittefirstbapti2061
rather than focusing on abbreviations the rest is great could you also include more documentations examples, perhaps admission and discharge note too.
@kaitycherismay1320
@kaitycherismay1320 4 года назад
Hi I would like you to do more video on nursing documentation please, I’m a new RN This is my challenge right now thank you
@Moye89
@Moye89 8 лет назад
This was super helpfull! Thank you as always
@djfooboo
@djfooboo 9 лет назад
NPO = Nil per os It's latin
@jodiehaley9003
@jodiehaley9003 9 лет назад
Wow.. does every nurse use this?
@ashleighjoan
@ashleighjoan 9 лет назад
Very helpful!
@empowern
@empowern 9 лет назад
ashleighjoan Hi Ashleigh! Thanks so much for letting me know!! Always a pleasure seeing you!! See you soon love!! xoxo - Caroline
@يوسفالمدهون-ب8ح
@يوسفالمدهون-ب8ح 5 лет назад
Thank you 🙏 🙂
@empowern
@empowern 5 лет назад
Your welcome!
@sidrah283
@sidrah283 3 года назад
You''ll be surprised some doctors don't know abbreviations, I had the dean of a medical school tell me he didn't know what BIL means lol.
@datushyness5350
@datushyness5350 5 лет назад
Please I don’t have Dropbox can you add another link that enable us to download the I will appreciated.
@empowern
@empowern 5 лет назад
I will look into the link. You can open up a free Dropbox account!
@betsyperalta65
@betsyperalta65 3 года назад
I can’t see the link any more :(
@clifftanyzeigler658
@clifftanyzeigler658 4 года назад
Omg all those abbreviations 😫
@sally9805
@sally9805 4 года назад
Exactly, too much and not recommended.
@marygracedecastro5453
@marygracedecastro5453 9 лет назад
What's your hair color?
@amidahyusof4493
@amidahyusof4493 4 года назад
Nursing in hospital. Good job
@azouz1413
@azouz1413 8 лет назад
amazing
@missslowpoke1
@missslowpoke1 5 лет назад
Your link is not woking
@peace3791
@peace3791 5 лет назад
documentation is my weakness because of my English. Please teach me how to write without wasting my time.
@lizkeith1356
@lizkeith1356 5 лет назад
please, fellow nurses, watch the movie VAXXED.
@1purapericulo
@1purapericulo 7 лет назад
Omg thank u
@ShawnaCostonPhD
@ShawnaCostonPhD 7 лет назад
Cool Charting coding notes.... LoL.
@joshperry5367
@joshperry5367 5 лет назад
You have a spelling error in the intro, it should be where not were.
@tonicrvnts
@tonicrvnts 4 года назад
Nursing boards and hospital do not want nurses to use abbreviations at all 🙄
@Je-uu3bw
@Je-uu3bw 6 лет назад
avoid the word "appears"
@dancassidy7471
@dancassidy7471 3 года назад
P.T physical therapy
@efsherwood
@efsherwood 6 лет назад
Great advice, but WAY too much editing. Very distracting.
@dancassidy7471
@dancassidy7471 3 года назад
R.T. resp therapy
@thepro405
@thepro405 6 лет назад
smile more .you look like tha scary coworker .
@MartFinds
@MartFinds 8 лет назад
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
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