I am a year into this field working in the hospital. my concern is charting and what you MUST always make sure you document on.
I know to document my assessments, change in status, calling the doctor, etc. I did not realize that I needed to chart every time I informed my charge nurse of something. This was not emphasized during my orientation in the hospital. Mainly Physician contact.
But what things should nurses ALWAYS make sure they chart on? I wish in nursing school
they had given us a topic or course on defensive charting. I want to protect my license, but I am knew and there is still a lot I don't know.
Your advice is greatly appreciated.