Okay, I just started my first job as a Clinical Assistant while I'm in school for nursing (hopefully I'll start my clinical program next fall). My preceptor is telling me that when I chart vitals and the procedures I do, I should put in the time done at the time I put it in the chart. But when it's busy, sometimes we grab vitals on 6 or 7 pts in a row before sitting down to chart. Since I'm still learning, it takes me a while to get each set of vitals, and by the time I'm done with 5 pts, it's been almost a half hour since I did the first pt. Should I put them all in at the same time, or write down what time I took them along with the vitals so I can put that time in on the chart?? My preceptor puts them in as the time she's charting, so for example she has 7 pts charted that she did vitals at 1900, when she really did the first pt at 1830, second at 1840, etc. I don't want to get in trouble for charting errors, and if I ask the nurses, they'll tell me to ask my preceptor, or if I explain, I'm afraid I'll get her in trouble and the next 5 weeks of my orientation will be a living h*ll. What should I do? I would think it would matter to document what time the vitals were actually taken if it's that much of a time difference??
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