SimChart Charting Requirements for OB/Peds 1. Pre-Clinical Manager- All Must be completed a. Medications-All Medications i.

Must put something in every box under each medication 1. Comments-place N/A in this box or put page # from drug book 2. Action-Indication for use for your specific patient 3. Side effects or adverse reactions: Underlined in med book 4. Recommended dose ranges: Write your patients dose and whether it is safe 5. Therapeutic Effect: Write in your own words what this med will do for your patient when it is therapeutic. 6. Contraindications: Specific things you may hold this med for. (Ex. Low BP, lab ranges, etc) 7. Life threatening considerations: Red in drug book. 8. Nursing interventions: What am I going to check for before giving this med? b. Diagnostic Test: see below c. Laboratory-OB-All labs & Peds-Only enter abnormal, leave all others blank. i. Definition and description 1. What does the lab manual say? ii. Significance 1. Why is your patient having this test? d. Diagnosis-If this applies i. Pathophysiology: More than one sentence. In your own words describe the disease process and how that effects your patient ii. Therapeutic Regimen: Look at what is ordered for your patient: meds, labs, interventions, etc iii. Current Health Problems: Patient specific. 2. Patient Charting a. Admission History i. Unit Orientation ii. Allergies iii. Spiritual/Cultural iv. Psychosocial Assessment v. Drug, Alcohol, Smoking screening vi. Anything else your instructor requests b. Systems Assessment i. Document ONE for each day c. Discharge Planning d. Systems Nursing Interventions i. Document anything applicable that you did

3.

4. 5.

6.

7.

e. Basic Nursing Care i. Document anything applicable f. Special Charts: If applicable. i. Pain ii. PCA flow sheet iii. Labor flow sheet iv. Miscellaneous nursing notes**see below** g. Wounds, IV, Drains, Ostomies, Injection Sites i. Document if these apply ii. This is where you would document an epidural. Also, you would need to put the medication under meds. iii. Tattoos and piercings under wounds Vital Signs a. Peds/Non Active Labor/Postpartum-Chart every four hours, unless patient requires more frequently. b. Active labor-every hour Patient Teaching a. Document everything you have taught your patient Care Plan-2 care plans total a. Peds-One physical diagnosis and one developmental diagnosis b. OB/Postpartum-One physical and one psychosocial c. If you are in the OB and Postpartum in one shift, you will do one care plan for each area. i. One diagnosis=ONE outcome, therefore, you should have 2 diagnoses and 2 outcomes per weekend. ii. Interventions: Only use the ones that are applicable to your patient and that you will be able to evaluate. In other words, dont pick 20-40 interventionsthere is no way to carry all these out which means you will not be able to evaluate these. d. You MUST evaluate interventions and outcomes on EVERY care plan. e. Instructors like to see ADDED. f. Every intervention must be patient specific, measureable, and have a time frame. Other a. Make sure to document code status and diet on each chart. b. Your blue bar at the top must be filled in. Reflective Journal a. Each week you will submit a reflective journal. b. This will be typed into the Miscellaneous nursing notes. c. This should include: i. New Learnings ii. Challenges iii. Feelings iv. Changes

v. A general reflection of how your weekend went. d. This should be at least a paragraph, not a one word answer. e. This is not a minute by minute replay of your weekend. 8. Miscellaneous Nursing Notes a. If you cant plug in the info elsewhere please document it here. b. Chart by exception every 2 hours, this is where it should go but should not be a repeat of your head to toe. Ex. 0930 Resting comfortably in bed, no distress noted. Side rails up x 2, bed rail in low position, call light in reach etc. c. When documenting on a flow sheet(ex. Labor progression) you should document here see Labor flowsheet. Tips: 1. 2. 3. 4. Every aspect of your charting needs to be patient specific. When doing your care plan you do not have to select a medical diagnosis. Your instructor is a valuable resource, use them wisely If you have 2 patients you will have to have 2 simcharts.

***YOUR CHARTING MUST BE SUBMITTED BY WEDNESDAY AT 11:59PM, LATE WORK WILL RESULT IN DISCIPLINARY ACTION***