Charting, what is your protocol?

[NewlyGradBSN]

With regard to charting, Im curious as to what is your protocol? What type of charting do you use? What if amidst all the chaos, you were not able to close a chart? What are your strategies for faster charting? Thanks for the info:)

[FancypantsRN]

Protocols all depend on what type of nursing you are doing. ICU usually every hour, step-down/tele, usually every 4 hours and I think med/surg every 8 hours or every shift.

In the ER, we chart 1 assessment when they first come in, then everything else is progress notes.

I am not sure what you are asking with the chart not closing, do you mean if the computer locks up? On most systems I have seen, you have to just start over on another computer if it doesn't save it. The system I am on (T-system), you can log into another computer and pick up from where you left off. It's pretty nice.

Tips for faster charting? That just comes with time. Once you get used to the system, you know the drill and can fly through it pretty quickly.

[tyvin, BSN, RN]

Charting by exception, SOAP, etc... there are many ways to chart but usually the facility will dictate what type they want and when depending on the circumstances ... tele, ICU, ER, LTC, etc... Especially with manual charting going on the way side it may be up the the software as well.