Types of Writing
Charting
Information for charting is taken from the chapter "Documentation and Reporting" in Clinical Nursing Skills by S.F. Smith, D. J. Duell, and B.C. Martin, (Upper Saddle River, NJ: Prentice Hall Health, 2000), 45-66.
Charting has many purposes, including communicating information, assisting evaluation, and providing a legal record (Smith, Duell and Martin, 2000).
Content should include "the assessment that you completed at the beginning of your shift" which "provides a baseline for changes that may occur later in the client's condition" (p. 48). Most of all, your notes should emphasize any "changes in the client's medical, mental. or emotional condition" (p. 48). You should also include any "reactions to unscheduled or prn medications" and the "client's response to teaching" (p. 48). If you use flow sheets for certain "repetitive aspects of nursing care, such as vital signs and intake and output," you do not need to include those aspects in your notes (p. 48).
"The three main charting systems are source-oriented, problem-oriented,
and computer-assisted charting" (p. 49). In the source-oriented
charting system, "information is organized and presented according
to its source" (p. 49), so that doctors and nurses notes are separate.
In the problem-oriented charting system, "the chart is based on the
problem list--all problems, present or potential, identified with that
client" (p. 49). In computer-assisted charting, information is "constantly
update[d] ... from many sources" (p. 49).