Are you good at charting in "real time?"

[Ativan]

Are you good at charting/documenting in "real time," that is getting your assessments and vitals charted close to the time you actually do them instead of catching up with charting hours later at the nursing station? Any tips for how to do this successfully without delaying the rest of your care? Are you faster at documenting than all your co-workers, and if so, any tips?

Our hospital is pushing nurses to start documenting closer to real-time because the charting will be linked to patient acuity. I'm curious to see if this is actually humanely possible; looking for examples of nurses who successfully do this.

Thanks for any advice/opinions you might have!

[Lennonninja, MSN, APRN, NP]

I chart temperatures, I/Os, and any drip titrations in real time. New admissions I always chart in the room for my initial assessment so I don't miss anything. Anything else I can chart later after I get my night started. I get all of my baths done asap and all my preparations for the end of my shift done by 2200 so that I can focus on charting and reading progress notes later on. My vitals are imported from the bedside monitors with just a few clicks, so they're easy to save at any time. I always like to chart everything in the same order every time to ensure that I don't forget anything.

[ORNerd, BSN, RN]

It depends. When I was on orientation and working days, I got down a great routine and would do all my assessments, document them in the room, then pass all of my meds. When I was off orientation and starting rotating days and nights, I suddenly became more disorganized. I just can't seem to get myself together on a day shift anymore and usually end up doing an assessment with a med pass and then chart everything later. It all ends up getting done by the end of the shift but I do wish I could work straight days and get my routine back!

[turnforthenurse, MSN, NP]

As an ED nurse, I try to do real-time charting as much as possible. Sometimes it isn't always feasible, though, like in a truly emergent situation. Oh, my patient isn't doing so hot and they need this, this and this but HOLD ON, I just started that IV so let me go chart it. That's not realistic.

[nursey246]

I'm not a fan of real time charting .. but I am at the same time. I'm not because feel like the patient thinks I care more about the computer than them. However, when it comes to time management, it's glorious because you're constantly caught up.

I work in critical care, so I always have two patients. I assess my first one and chart my assessment in the room. Then I go get meds and go see my second patient, do my assessment, chart it, and by that time it's 0800 and can pass my 0900 meds. Then I go back and give my 0900 meds to my first patient.

We also have a code documentation thing that's done real time and it's great. Afterwards, you can focus on the patient's care or comfort the family.. not frantically charting and looking at scrap pieces of paper.

And if I'm in a rush, what I'll do is quickly chart my abnormals in my assessments and go back later to chart those things that never change. That way, I'm always accurate and on time.

Real time charting can slightly hinder patient-nurse relationships (in my humble opinion), however it is GREAT for time management. There's no "wait.. when did I do that? Were his lung sounds diminished or clear? Did he have a murmur.. I can't remember?" anymore, no re-doing anything because you can't remember. I think if you look at your real time charting with the same, although slightly less, priority as your medications, you'll find yourself clocking out on time and a lot less stressed.

[CodeteamB]

As an ED nurse I try to do real-time charting as much as possible. Sometimes it isn't always feasible, though, like in a truly emergent situation. Oh, my patient isn't doing so hot and they need this, this and this but HOLD ON, I just started that IV so let me go chart it. That's not realistic.[/quote']

True, but in that kind of situation we would usually have one person charting, love codes for that reason... I'm either charting or doing, don't have to balance both! Also, I do block chart, so I will finish everything I am doing with a patient at a given time, and then chart, by real time I mean that I chart right after I finish instead of putting it off until later in the day as I see some nurses do.

[nursefrances, BSN, RN]

I would try to do my assessment while bedside with the patient whenever possible. It depended on how the morning was going and if I didn't have any interruptions or too much craziness going on at once.

On a perfect day I would try to assess then at least do the assessment portion of my charting in the room. After med pass then I would sit down and complete all the many other screens I needed to do.

Now that I am in an ambulatory surgery center all charting is real time, I pre-op or post-op the patient, document, then on to the next patient. ( "Next" )

[TiffyRN, BSN, PhD]

When I worked with adults and had 4-6 patient assignments I usually ran around from 1900 to about 2200 doing assessments, cares, meds & so on. If I could get all my charting caught up in half hour but honestly that was rare and didn't usually happen until 2330-0000 once everyone got MN vitals and sleepers.

Now that I'm NICU things are different and generally more regimented. Most cares are done by 2130. I usually manage to get charting done from then until 2230 when the next set of cares rolls around. It's all computer charting so I try my hardest to get everything that happened before MN charted by then because it's several extra steps to backdate something to the previous day.

Working one's shifts in a row is quite advantageous as one can copy/paste, review and modify as needed pretty quickly; especially those care-plan interventions that rarely change.

[mmc51264, BSN, MSN, RN]

I try my hardest to get my charting done in real time. We have computers in the rooms, so it helps. If I am in a rush, I might do a quick look at wounds and lines, clear pumps, etc. I try to have everything including a note done on all (I usually have 5 pts) before noon meds.

[akulahawkRN, ADN, RN, EMT-P]

I try my hardest to get my charting done in real time. We have computers in the rooms, so it helps. If I am in a rush, I might do a quick look at wounds and lines, clear pumps, etc. I try to have everything including a note done on all (I usually have 5 pts) before noon meds.

A couple of the facilities I've been in so far have computers in each room. Those places usually still have computers at the nurse's stations and occasionally mobile workstations as well, but fewer of them because there are those room units. Mostly the mobile workstations are used as backup workstations in the event that the room computers go down because they can also do the med scan stuff. The facility I'm at now doesn't have computers in the rooms but they do have a lot of mobile stations, but just enough. The older ones have a very limited battery life, so they just don't last long if you must unplug from the wall.

If I'm at a computer, I'm charting or doing research.

[Hoosier_RN, MSN]

LTC, still doing paper, slowly integrating to computers, supposedly by end of year

[akulahawkRN, ADN, RN, EMT-P]

LTC, still doing paper, slowly integrating to computers, supposedly by end of year

I truly feel for LTC folks that transition to computer. It's hard enough to chart on 3-4 patients... but if you have to chart on 4x that, it's going to be nearly overwhelming. I truly, truly feel for you. I do!

[CelticGoddess, BSN, RN]

I am able to get my vitals in in "real time" but am not able to get my full assessment in in real time. I do my full assessment when I do my 2100 med pass. There is no way I would be able to pass meds, assess and chart and get it done within the time frame allowed. (Start my med pass at 2030 and have it done by 2200). Assessment charting takes forever anyway due to all the forms, there are times that I think it takes longer than the actual assessment.

Edited because my computer hates me.