The New Grad & Charting - page 2

by CoffeePVCs | 4,824 Views | 12 Comments

i'm a two week old new grad! in clinical, i was only exposed to "click click" "scan scan" computer charting, and making "clinical notes" as needed. the tele floor i work on is a whole different way of charting. it is our... Read More


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    When I was a new nurse, we charted everything we did, and were told that if 'we didn't chart it, we didn't do it'. My second job required charting by exception. I had a hard time with the transition. Your point is valid that if there is a discrepancy between two documents it might make you seem dishonest. But, worse, another nurse got pulled into court because of a hospital error. She charted by exception, so she hadn't written down her numerous checks on this patient (and by then couldn't remember because it was years later). The lawyers made it seem that she had neglected the patient.
    livelikegold likes this.
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    Quote from DanaNP
    When I was a new nurse, we charted everything we did, and were told that if 'we didn't chart it, we didn't do it'. My second job required charting by exception. I had a hard time with the transition. Your point is valid that if there is a discrepancy between two documents it might make you seem dishonest. But, worse, another nurse got pulled into court because of a hospital error. She charted by exception, so she hadn't written down her numerous checks on this patient (and by then couldn't remember because it was years later). The lawyers made it seem that she had neglected the patient.
    Just reading your post has me on edge. Im a student nurse due to graduate in a month...... WOW life just got scary
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    DanaNP,

    I use the patient safety check on the flow sheet. If there is a particular issue, like a known DVT I'll document the extremity q1-2h "+2 pedal pulse, cap refill <3 seconds, no change in circumference..." otherwise, I'm say what the pt is doing, respirations, pt requests, family visiting, dr visits.. things like that to notate I am in their environment frequently.

    I went to the bookstore today and grabbed a bunch of 1st year nursing and charting books, it's nothing I haven't really heard, its just a matter of me getting a grip on doing it under pressure. Right after something happens I feel so drawn to catching up on tasks that stopping to document seems like something I can make notes about and fill out later, but I am changing that school of thought. Documenting the event should be of equal importance with catching up. If something happens, pt condition changes, someone needs to read my notes asap, I need to have it laid out to be viewed.
    Thanks for all your input, like to hear more. Hope this thread helps other newbies. As for the two week old comment, I feel like that


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