Nursing Documentation-if you didn't document it, you didn't do it!

Thank You! I will print these off and keep them handy for when my mind goes blank.

When you do let me know, please. I feel the same way. Lost, only time I stop for 12-13 hours is to go to the bathroom a couple times. Stay behind. always. 4-8 or so patients. I am trying, I am 44 and have spent twenty years with the desire to get where I am now, I have only been lic for few months. I will not give up.

Are those standard orders or did the physican personally write to notify him of that BS?
That does sound a little odd to me. Maybe the patient has some serious issues with this
sort of thing, you just have to use your best nursing judgement and chart that he was called
and chart any orders that were received. According to the other nurses response, it sounds
like to me that these are orders that show up on everybody and if that is the case, sounds
like something needs to be changed, possibly call your pharmacy or ask your manager why
such standing orders as this exist. At our hospital, we have a certain policy to notify physican
if BS greater than 350, and use hypoglycemic protocol if less than 60.

You will get the hang of it very soon. I've been doing this going on two years and it does
get better.

You gave some very practical advice; thanks! What follows isn't about your specific response here. It's about the advice that newbies hear a lot from different sources:

It is very true and valuable to recognize; however, to my sensibilities, this can come across as disheartening to newbies.

In the future with more experience, the newbie will have more confidence in their judgement and will learn to use it when appropriate. *Until then*, what's a newbie to do? Ask questions, check policy, take extra potentially unnecessary steps just to be safe. For that, in some cases, the newbie may get criticism: warned that they're too slow, exasperated eye rolls, told that something should have been obvious. In other words, there can be an implication that the newbie *should've known* what they are being corrected on and that maybe they just don't have what it takes to be a nurse. And I'm not talking about overtly irresponsible behaviors or serious endangerment of patient safety.

To me, in some cases, to tell a newbie nurse to "just use your best nursing judgement" feels akin to asking a first year piano student to teach themselves to play a concerto and not rely on an instructor or coach to "coddle" them; after all, they know how to play a piano, don't they?

Thanks for that sample charting. I printed the whole thing out and am going to keep it with me at clinicals as examples. Thanks for posting!!!!