Nursing Documentation Tips!

EmpoweRN.com
Thank you so much for watching!
Here are Mighty Nurses social sites & website! Make sure you follow them :) they will keep you laughing :D
www.Mightynurse.com
Their Facebook: goo.gl/exc2N3
Twitter: / mighty_nurse
Pinterest: / mightynurse
Here is the dropbox link with the documentation tips:
www.dropbox.com/s/qtvlr1nirvd...
Keep in touch!
xoxo
- Caroline

[@VarioUS5674]

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.

[@karenkuwahara4619]

I wouldn't say "appears" in documentation. That is subjective. Use objective statements like "pt no longer exhibiting signs and symptoms of....."

[@andrearackley7508]

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]

+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

[@angelawiggins5377]

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!

[@katherine3324]

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]

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

[@ErikaEHE]

I just found this video & I wanted to say thank you for all of your helpful tips👍

[@lylyicing]

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]

This was very good and very helpful for us nursing student, thanks a bunch Caroline!

[@empowern]

Tina Ortiz Hi Tina! Thanks so much for letting me know!! So glad you liked it! xoxo - Caroline

[@aiiyiabear2414]

You're my inspiration and motivation to keep being strong in nursing school! Thank you

[@MansonxXxAddiction]

Thank you :) practical assessment including documentation on friday, great tips that i will remember to incorporate!

[@cashaldrarobinson3579]

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]

+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

[@brookelynn14]

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?

[@mnj6773]

I'm so glad you did this video & thank you so much for the link with the documentation tips link!! :-)

[@empowern]

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

[@rgvmarciano]

Caroline, thanks for sharing! These tips are always a blessing.

[@empowern]

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

[@emersonarchuleta]

Thanks for posting this one. Very helpful as always!

[@empowern]

emersonarchuleta You are so welcome love! Thanks for letting me know it helped. See ya! -xoxo

[@ehhssh]

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]

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]

Abbreviations seem to be a sure fire way for newbies to misunderstand things though...

[@DianaJimenezMUA]

Can you do more of these videos please!! truly helpful, new RN here. lol

[@nursenzi]

I agree ☝🏾

[@belbes01]

amazing nursing documentation tips. thank you so much it help me on my nursing documentation.

[@natalie-kn9fj]

Thank you so much for this video. Very helpful

[@wehttamak]

would love more documentation tips ...... system assessment when taking over a patient ... thanks for the tips

[@pamtodd6143]

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]

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

[@zahraaalhaieri5091]

That was such a helpful video. I think you're so intelligent Caroline.

[@empowern]

Rose H Thank you so much Rose!! The feeling is mutual ;) xoxo - Caroline

[@williamewing7124]

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.

[@erikamartinez4788]

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]

+Erika Martinez Absolutely! That's true :)

[@leahenry8044]

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.

[@MartFinds]

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

[@BlushnBlue]

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]

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: kzbin.info/www/bejne/hn-UqWd9nqatjM0 Please let me know any video request you have as a new graduate!! And again! CONGRATS!!!! xoxo - Caroline

[@Moye89]

This was super helpfull! Thank you as always

[@jugy4656]

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.

[@methusellahparnaso4958]

Thank you so much for another great video! I hope you can make more videos in documentation! Thanks!

[@empowern]

Methusellah Parnaso Thanks love! For sure!! so keep posted. See yah! -xoxo

[@lbredikhin5]

Thank you! I have trouble with skin documentation... Any tips?

[@donnalockett7532]

How often should I document on my patients?

[@Ferouzah]

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]

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]

dddemarino i

[@mikeyanatomy]

Thank you for your examples!!

[@empowern]

+mikeyanatomy Your welcome!

[@erikamartinez4788]

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]

+Erika Martinez Awww you're so sweet! Thank you!! I'm sure you're a blessing to everyone too. -xoxo

[@Stacyann_1]

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]

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]

In the UK, the Nursing and Midwifery Council advise against abbreviations too. They are used all the time in verbal communication though.

[@SLV0707]

Thank you for uploading. Please more videos about documentation. Btw, the dropbox link is not working.

[@puzz88]

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

[@sukeertyacharya6436]

which one is the standard tool for nursing documentation ?

[@tarah58]

can i use the documenting skills as an lvn/lpn also?

[@jamie50308]

Great tips/advice!

[@aminazahra2011]

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?

[@TheAmber1030]

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!

[@steffacation]

Great video idea! Thanks for all the tips!

[@empowern]

Steffa Dee Hi Steffa!! Awesome! Thank you so much for letting me know!! It means a lot :) xoxo - Caroline

[@mikachavez6118]

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?

[@Selene0017]

Super helpful! Thank you very much

[@empowern]

Selene0017 Awe yay!! Thanks so much for letting me know that you liked it! See you soon! xoxo - Caroline

[@annaleerose8620]

Very informative, please post more like this.

[@empowern]

annalee rose Hi Annalee! I will definitely have some more coming. Keep posted. See ya.. -xoxo

[@NurseMurse]

I found this video very, very helpful! Also I was late to getting in your inbox. Ttys!

[@genevievemiranda5185]

Best video yet

[@gmax1267]

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]

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]

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 !

[@NurseBass]

Haha, for a very split second you were like "What's the "R" in "SBAR" stand for again?" :p Great video Caroline!

[@mairn2522]

Recommendation

[@jodiehaley9003]

Wow.. does every nurse use this?

[@kevin18887]

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]

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

[@2012foreverneo]

Having to write my first Nursing Notes for Fundamentals class and this video helped me tremendously!!! Thank you thank you thank you!!!!!!! :)

[@empowern]

+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

[@marygracedecastro5453]

What's your hair color?

[@pamtodd6143]

SBAR definitely and do you deal with a lot of docs with hard to understand accents? Any advice

[@empowern]

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]

***** I vote for a SBAR vid :) great idea!

[@Carahie919]

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.

[@Randimal762]

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.

[@betsyperalta65]

I can’t see the link any more :(

[@ashleighjoan]

Very helpful!

[@empowern]

ashleighjoan Hi Ashleigh! Thanks so much for letting me know!! Always a pleasure seeing you!! See you soon love!! xoxo - Caroline

[@nannzarzarkyi6985]

looking forward another daily report.

[@missionscommittefirstbapti2061]

rather than focusing on abbreviations the rest is great could you also include more documentations examples, perhaps admission and discharge note too.

[@user-pp3jc1gm4s]

Thank you 🙏 🙂

[@empowern]

Your welcome!

[@sally9805]

All those abbreviations when you just been told never use abbreviations or acronyms unless it's okay with your hospital.

[@djfooboo]

NPO = Nil per os It's latin

[@datushyness5350]

Please I don’t have Dropbox can you add another link that enable us to download the I will appreciated.

[@empowern]

I will look into the link. You can open up a free Dropbox account!

[@azouz1413]

amazing

[@dancassidy7471]

As M/B instead of ad evidenced by ..blessing!

[@kaitycherismay1320]

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

[@missslowpoke1]

Your link is not woking

[@cherrysantos96]

Good thing we sont abbreviate in my workplace. Thank God coz that would be stressful to know what others' made up abbreviations

[@1purapericulo]

Omg thank u

[@sidrah283]

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.

[@clifftanyzeigler658]

Omg all those abbreviations 😫

[@sally9805]

Exactly, too much and not recommended.

[@peace3791]

documentation is my weakness because of my English. Please teach me how to write without wasting my time.

[@joshperry5367]

You have a spelling error in the intro, it should be where not were.

[@lizkeith1356]

please, fellow nurses, watch the movie VAXXED.

[@amidahyusof4493]

Nursing in hospital. Good job

[@Je-uu3bw]

avoid the word "appears"

[@ShawnaCostonPhD]

Cool Charting coding notes.... LoL.

[@dancassidy7471]

P.T physical therapy

[@tonicrvnts]

Nursing boards and hospital do not want nurses to use abbreviations at all 🙄

[@dancassidy7471]

R.T. resp therapy

[@thepro405]

smile more .you look like tha scary coworker .

[@efsherwood]

Great advice, but WAY too much editing. Very distracting.

[@MartFinds]

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