Name : Bening Afri Dalilah

NIM : 205070209111019
Class : SAP SMT 3
Subject : English 2

Topic: How to Understand a Patient’s Chart as a Nursing Student or New Nurse.

Source: https://www.youtube.com/watch?v=lNwRvKaNsGc

Nursing planning can be optimal by selecting the most important information to provide
care to patients by making a kind of "nurse report sheet" itself. Charts contain lots of
information clinicals to do a care plan on a patient. Every system at a hospital is set up
differently program. So the key if we want to get familiar with the place that we are working
with what type of stuff they use like online chart or paper chart.
Now online charts are better than paper charts because we can see patients who have
been hospitalized before and if they were there five years, like why they were there if they
had a heart, what was their heart, showing everything like that and before that it was just in
paper charts and we had to call medical records and there would be delays and it really
hindered patient care so online charting was really awesome.
The uses and benefits of nursing report sheet are guide for studying and reporting on
the patient's condition, contains important information about: patient diagnosis, history,
allergies, attending physician, consultation, things to do on nurse shift, treatment time, vital
signs, lab results, etc and help nurses separate patients, check whether or not the patient's
plans/interventions have been carried out.
The next part that we want to pay attention to is the practicum section. Patient charting
is also important can help us to do our job. The first part is vital signs and flow sheet. From
here we can find out such as temperature and blood pressure. Flow sheets can help us to
find information for infusion when the IV needs to be changed central line he needs a tube
dressing or wound care. The next section is nursing notes. So it can be concluded that the
benefits of "Nursing Report Sheet" include:
a. Quick access to patient information. If you are asked by a doctor what the INR of a
particular patient is, you can simply look at your report sheet to find out. You won't be
fumbling and trying to remember which patient he's talking about.
b. Helping you keep track of the things you need to get done before your shift is over.
c. Help you keep your charting more accurate. If you write down on your spreadsheet the
things you need to remember to map, your charting will be more accurate and easier to
do. Again with 6 to 7 patients, everything tends to go together.