New grad, common mistakes

  1. 1
    So, i just came up on my 1 year as an RN. I feel like i am doing ok, and right where i should be. However; i feel like i'm ALWAYS falling behind on my charting and forgetting something. Usually i get it in at the end of my shift. We can back chart, which is my savior. So i can chart at 7pm something that happened at 8am if i really wanted.

    It's so frustrating, and i feel like i am so alone with this charting stuff. Today i discharged a patient, and forgot to chart that i took out the IV. I realized it AFTER i discharged him. I went back to his chart and charted the time i did it at.

    is this common? or am i the only one feeling like i am struggling with this??
    carolmaccas66 likes this.
  2. 11 Comments so far...

  3. 1
    As you are a nurse longer, you will get into your groove. You will automatically have things you chart. things you do automatically and don't really "think" about it much. forinstance. When I pull an IV I always look at the canula. I do this without thinking because I have been doing it for so long. so when I chart that the IV was removed I chart "IV removed c canula intact. no redness or drainage noted. bandaid placed."
    carolmaccas66 likes this.
  4. 1
    No, it's common to get behind - there's just too much charting.
    I work ED now and we always put the times that an IV is started, but often don't get time to chart the time it finished. No-one ever remembers, and keeping FBCs up to date is a nightmare. I went and worked psych the other night in a private clinic, and stable patients there have VS/OBs done once a day at the very least. Some hadn't had VS done for 2 days, and some had cardiac/renal conditions. Hardly any UAs had been done, and no admitting weights were done either; weights were done if the doctor had specifically requested a weight every day. Some only had half the VS done. I couldn't believe how slack these people were!
    In Oz we legally have 48 hours to add to our charting; after that time, it really doesn't matter.
    Do u use a cheat sheet with patient names and times, to cross everything off as you go. Also ALWAYS start your charting/patient notes as early as possible, cos u never know what will come up later.
    There are many threads on time management on here, just google them, and they should give you some good tips.
    Also do a quick check of your charts etc b4 the end of your shift, or right after handover as I do. Also if u get home and think - I didn't chart such-and-such, then call the facility and they can write it in, ie: nurse Smith rang @ ___ time and reported a BSL done at ___ time. This is still legal - the other nurse doesn't sign it, just records that you have rung in and the time it was recorded.
    I've been an RN for 3 years - I took out a lady's IV the other night and couldn't record it cos the doctor had walked off with her chart - I went home & forgot all about it. But that's not something urgent you would have to report, if you know what I mean.
    Time management all takes time and practice, and sweetie, I've worked with RNs who have nursed for 18 & 20 years who STILL get behind! So it's not just you! Do things in a methodical manner and control your shift and your patients - or they will end up controlling you, I always say.
    Let us know how you get on anyway, OK? I think you will be fine!
    MSHAH647 likes this.
  5. 1
    You are fine, you will get better with time. I felt the same way. Just go
    in with the intention to do your best and be mistake free. Mistakes will also happen. My stupid @as once discharged a patient with her foley still in place. After work I had to drive to her house and take it out, lmao. Now that was he dumbest thing I've ever done. So at least you know someone is worse than you. I also had a patient code at 6:58p, right at change of shift. Girl I didn't leave that hospital until a little past 11 pm
    fashionistaRN likes this.
  6. 2
    OK... let say the case goes to court.
    Lawyer: "So, you are saying when you got home the IV was still in place"
    Plaintiff: "No"
    Lawyer: "Then go pound sand."
    Worry about charting the big stuff and tell the administration the minutiae is annoying and not your priority unless they intend on staffing more people.
    joanna73 and pinkchris2000 like this.
  7. 0
    thanks for replies! i always felt like there was something wrong with me. Administration is all over us for "missing something during charting" seriously, do they have someone actually sit and look through all this crap?? (i hope their lives are very depressing).

    I cannot tell you the little tiny things i have missed then i have been called out on. "Why did you chart their cardiac was WDL when their heart rate was 110? Normal is 60-100. Did you page the doctor on this change in status?"....yes, i got a call on that once. AT HOME EVEN!
  8. 0
    I've been a nurse now for about 3-4 years, (some prt time) and I STILL feel this way. It's as if I get worse as time goes on, it seems, lol.

    Throw in a demanding nit picky family and I'm toast.

    If it's bad, I have no problem calling the shift on duty and asking them to fix things. They are usually too happy to do it ...I feel like a nincompoop, but oh well.

    Today I am up early in the a.m. thinking about my prior shift and everything I didn't do charting wise. It's just too much.
  9. 0
    Quote from Jenni811
    is this common? or am i the only one feeling like i am struggling with this??
    Experienced nurses on my floor have the same issues. Some are better than others.

    I can tell you that the most criticized former nurses on my floor are the ones that always had PERFECT charting. They had their head to toes done and flowsheets filled out by two hours into their shift.

    However, they (reportedly) provided rotten patient care because they were too wrapped up in making sure all the blanks on the charting were filled in.

    I make sure my VS are all in as soon as they are taken and I try hard to make sure that signout reports with valuable information are complete by the time the next shift arrives. The other flowsheet charting can wait and I pound all of that out when I can. (Of course I chart all meds when given. That never waits.)
  10. 2
    I have my report sheet on the right and a blank sheet of paper on the left so that they are facing each other on one spread.

    Because I'm a new nurse, and I desperately want to get the "big picture" from the start (although I can't do it perfectly without support), I take a few moments after report and think about the patient's admitting dx, co-morbidities, and meds so I know what to watch for during my shift. I make a list of to-dos at the top (treatments, lab checks, specimen collections, potential discharge/transfer, etc.). Through my shift, I may add to the list.

    I also have two sheets that are placed in a prominent place in my binder: shift VS and insulin and med admin times for each patient. That way, I'm not running through the separate MARs every one or two hours to see if I have to pass a med. It also helps me carve out time for charting and when I can take my break.

    I carry my binder with me, except into isolation rooms. After I have done my assessment and gone through my list of to-dos, I jot down a few important notes about the assessment and the time of completion for my to-do list. I usually write as I'm walking away from the room toward the nurses station to save time. I also jot down times of when docs were notified: new consults, change in patient status, etc.

    Pertaining to the example you gave in your OP, if a patient is discharged, I also jot down the time of completed discharge and stuff like, "IV, Foley, dressing, wheelchair, DD (meaning left with daughter)."

    I'm still one of those nurses that charts actual times of activities, rather than throwing everything in a single charting entry. Assessment is done first, so that's the longest charting. Everything else is charted under different times if completed at different times, and it's much shorter. I try to chart assessment and other tasks completed after the first med pass, and then I do final charting right before report to the next shift for tasks, notifications, etc., completed the second half of the shift. I usually have two charting sessions for each patient that consist of anywhere from two to five separate entries, depending on the patient's needs.

    I started this routine only after I realized I was forgetting to chart things, and I too would have to go back into the chart to correct it.

    As I get more experience, I'm hoping all this stuff will be in my head. Right now, it's info overload, and I feel more comfortable jotting down stuff so I don't forget. Also, if I get an admit or something goes wrong/bad with a patient or family member, I don't forget the stuff for my other, more stable (and less time-consuming) patients. At the end of my shift as I'm walking to the time clock, I rip out all the sheets and throw them in the secure paper disposal bin.


    I haven't yet found my method to be time-consuming and a waste; on the contrary, I feel that my charting is more thorough and accurate, but I certainly don't have much downtime during my shift, except for my break.

    ETA: I also do one other thing that makes charting go faster. I have the facility's definition of WNL in a prominent place in my binder. I see a lot of double-charting of WNL, so I decided to chart only abnormals (unless it's neuro checks or something like that ordered q whatever). I had one younger, more stable patient with no comorbidities the other day, and her previous charting was very long with a lot of normals charted individually. I took a careful look at the WNL definitions and realized that I could just chart WNL within facility policy for many of her body systems.
    Last edit by dudette10 on Sep 11, '11
    ajtown21 and JRP1120, RN like this.
  11. 0
    Quote from MN-Nurse
    Experienced nurses on my floor have the same issues. Some are better than others.

    I can tell you that the most criticized former nurses on my floor are the ones that always had PERFECT charting. They had their head to toes done and flowsheets filled out by two hours into their shift.

    However, they (reportedly) provided rotten patient care because they were too wrapped up in making sure all the blanks on the charting were filled in.

    I make sure my VS are all in as soon as they are taken and I try hard to make sure that signout reports with valuable information are complete by the time the next shift arrives. The other flowsheet charting can wait and I pound all of that out when I can. (Of course I chart all meds when given. That never waits.)
    Omg, you like hit it dead on. I always felt AWFUL because i wouldn't get my head to toe assessments done by 11:00am, sometimes even 12:00. I always get so hard on myself because it's not done by noon! And others get theirs done at like 9am, im like HOW THE HECK DO YOU DO THAT?!?


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