Charting for Nurses | How to Understand a Patient's Chart as a Nursing Student or New Nurse

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


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 lasix and we

know that lasix 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 lasix like 60 milligrams you

probably want to hold off giving that

lasix 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

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