Mark Nursing Visit Report Form Made Easy

A Framework Supporting Registered Nurses To Maintain Standards, Form

hey everyone its Sal with registered nurse orange calm and in this video we're going to go over how to master a patient chart now as a nursing student or a new nurse the very first time you are ever exposed to a patient's chart you're going to think oh wow how am I ever going to master this material because charts contain a lot of information about a patient and whenever you're new you don't know what's important compared to this you don't know what you need to know to help you do your job so in this video I want to help you with those things I want to talk about what's the most important information in a chart I'm also going to talk about ways that you can master it help you to get organized and to learn how to filter out is this important is this not important should I look here should I look there and how to actually organize all this information for reference okay first let's talk about Charney charts like I said contain lots of information I remember whenever I was a nursing student and we had to go to clinicals to do a care plan on a patient in order to do a care plan you have to look through a chart and I remember looking through the chart and this was before charting was online online Torian has made things a lot easier which I'll go into here in a second but the chart was just in a notebook and I remember thinking how in the world am I going to know what to look for to develop my care plan and whenever I become a nurse how am I going to be able to pick out the most important information to provide care to this patient but it does come to you and in this video I want to give you some tips on how to do that okay first let's talk about charting every system at a hospital is set up differently every prospero is going to use a different program they're going to call things differently so the key is you want to get familiar with the place that you're working with what type of stuff they use because one place I work they had online charting most of it was online but some of it was still in a paper chart so you want to make sure that you're familiarize yourself with that now online charting is great because one thing that I love about it is that I can look at patient's previous previous hospital stays and if they were there five years ago I can see why they were there if they had a heart cath what their heart cath showed everything like that and before then it was just in this paper chart and you would have to like call medical records and there would be a delay and it really hindered patient care so online charting is absolutely awesome so first let's go over how to organize this okay very first thing that i really recommend whenever you were a nursing student or new nurse is that you get or you make your own report sheet template and let me show you a sample one on my website register nurse RN comm a link should pop up you can go and download some free report sheets and right here I have some report sheet templates you could double side print this and get for patients on it and it literally guides you with everything that you need to learn in a report because that's where you're going to learn a lot about in your patient then whenever you're going to be looking at the chart because you're going to look at the chart but you're also going to learn a lot in report so I really recommend you get one of these or develop your own you can look at mine and develop your own and and what these report sheet templates do they allow you have a quick reference for whenever a doctor ask you a question because you're going to have like five or six patients sometimes depending on what type of unit you work and the doctor might ask you a question and you have five patients like I don't know so you could bust out your report sheet template and see where that information is and tell them instead of having to find the chart and look through it and tell them the answer next and it helps you keep your patients separated because like I said you can have a lot of patients and they have similar things going on can just help you with that and also it's great to help you keep track of tasks like if you have to give medications you have a dressing change coming up anything like that and just to jot notes on but remember at the end of your shift every shift you shred that nursing report sheet template because you don't want to store in your locker take it home because it's a HIPAA violation okay here are some ways to master it and then I want to go over the important areas in the chart that you need to familiarize yourself with and go over to so you can master a chart okay ways to master it during your clinical time as a nursing student or your orientation period you need to take advantage of that this is time where you can literally just get in a cubby somewhere away from people go sign into the computer charting and just select a patient that you're assigned to and look through all this important information and see what's important what's not important and also whenever you're with your clinical instructor see what he or she is looking at what they are most you most likely to use and things of where they grab their information next learn what's vital to note which we'll go over here in a second and learn how to ask the right questions in rapport because sometimes you're going to have such a busy day that you're going to have time as a nurse to set down and to just look through that chart from top to bottom so you really need to know those important questions ask your report and I made a whole video on how to give report questions to ask and you can check that video out as well a link should pop up so you can watch that in next like I said beginning of the video learn your jobs systems charting a lot of places will offer a class or they require a class for new nurses to take on how to clinically document eight and they go through all the sections of the documentation and show you how to do that so if that is available for you take that because it's an excellent resource now let's go over the important stuff okay I have divided whenever you have a chart you have little tabs usually that's divided into flow sheets doctor's orders and you just click those and it'll take you everywhere you got to go or if you're still using paper charts and a notebook have little tabs that'll say H and P flow sheets things like that some of them are called different names but they're generally the same thing now I've divided these into two sections this part of the chart is what's going to help you learn your patients so you'll know what your patient's history is who this patient is what why they're there and can help you learn that part this part of the chart helps you do your job as a nurse and helps you keep on track with your nursing tasks so first let's go over the sections that help you learn your patient whenever you're looking through your chart you want to make sure that you're paying attention to the H and P which is called the history and physical section this is so important and it's such a great little section before I became a nooner before I became a nurse and didn't really know about this section so I was looking everywhere to try to find history information on a patient or their allergies and things like that all these different sections but the HMP literally has it exactly there and on this section it's completed by the doctor this is where your consult will come in and this is where your a mini physician and it will tell you what's going on with that patient what they presented with their signs and symptoms everything like that it will tell you their history their whole health history their surgical history their allergies their current medications and what's one of the most important things and what the doctor plans on doing their whole plan of care what and regimens are going to be started who they're going to consult what procedures others are going to order it's excellent so definitely pay attention to that part next the diagnostic testing results a lot of times patients are order chest x-rays echocardiogram stress tests everything like that and in this section you can go and see if the results are back and if so what they said and this helps you understand okay this patient was admitted with pneumonia let's go see what that chest x-ray showed because we've started them on IV antibiotics and let's see if they're getting better and a lot of patients want to know hey what in my stress test show so you can tell them so very important section next section that you want to pay a lot attention to is your lab work section all patients come to the hospital and they everyone gets blood drawn and and this lab work section will tell you hey how's their hemoglobin hauser electrolyte electrolytes and this is going to help you as the nurse taking care of the patient because say you're going to be giving some IV and we know that wastes potassium so if you're am Labs came back and your potassium level was only 2 and your the patient's ordered a 10 o'clock dose of IV like 60 milligrams you probably want to hold off giving that until you call the doctor and let them know that the potassium level was only 2 because you're going to bottom out that potassium if they didn't have any ordered so lab work is so important and plus in the morning whenever your labs start coming off on that section you'll want to call any abnormal results if it was abnormal the previous day or anything like that so that's really going to help you learn who your patient is what's going on with them now let's cover the section on the sections of the chart that help you do your job ok bottle signs and flow sheets this right here is going to tell you you can look back at vital signs some software programs that your hospital use will create beautiful graphs to show you how the temperatures have been have they been spiking how blood pressures have been and if you're getting your morning bottles you can say well the blood pressure was just 100 over 60 it's not normal for that patient you go back and see if that was normal or not so that's very important flow sheet flow sheets for IVs next time an IV needs to be changed central line dress he needs to be changed PEG tube dressing wound care very important you want to get familiar with all your flow sheets and nursing notes this is where your care plans are updated do you need to update the care plan is your patient having a new problem going on that you need to add a nursing diagnosis for that you guys need to concentrate on for the day a nursing notes you can look at previous shifts and see how this patient has been progressing and all of a sudden your patient becomes disoriented and is this normal for the patient because they have a history of dementia but did this happen the same time yesterday - the other day shift nurse oh you can get in those nursing notes and look at that very important and doctor's orders you're going to spend a lot of time on this section of your chart because a lot of times you may not see the doctor rounding because they sneak in and you can look at those orders see if they've ordered anything new see what your future orders are so you can be prepared for that that's a big section that's really going to drive what you're doing as a nurse and new medications that come in as well will be under this section and then next and the medication system some places is use a completely different program than their documentation program I know some places use a program called Mak Mak and it's just your medication administration system and it tells you every time medications do and that's a really good place to be looking because how many medications you're giving today is really going to drive how your day goes so that is some ways on how to master a chart so overall in conclusion I really recommend that if you're a nursing student new nurse that you get in there you look you practice you get your report sheet you jot down what's important you see what other nurses are always looking at watch your preceptor and just practice and practice and I promise over time you're going to learn this information and you're going to master it and you're going to think oh wow I can't believe I even had trouble with it because over time it just becomes second nature so thank you so much for watching and please check out my other youtube videos and please subscribe to this youtube channel