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This is a discussion on When do you do your charting? in General Nursing Discussion, part of General Nursing ... Is it better to get all your assessments, vital signs, patient care needs, etc done and then try...by Nurse ABC Jul 30, '12Is it better to get all your assessments, vital signs, patient care needs, etc done and then try and sit down for an hour (which you usually can't manage) and do all the charting at once OR chart in each patient room or right outside the door which would take over an hour to get all the assessments in? We usually have anywhere from 6-8 patients and sometimes more. I'm trying to figure out the most time efficient way. We have so many different pages of charting we have to do and it takes forever. Any tips would be so appreciated! Thanks!
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- Jul 30, '12 by NicuGalWe have everything on the computer so we chart as we do things. The only thing we leave for sit down are careplans.
- Jul 30, '12 by caliotter3I try to chart as I go because I have found that if I wait until the end of the shift, too many things get left out because I forgot or because I am in too much of a hurry. If not after every patient, I would do it after every three patients. Just how I would do it. YMMV
- Sep 21, '12 by Nurse ABCThanks! I'll try it that way!
- Sep 21, '12 by turnforthenurseRNWe have computer charting at my hospital. Anything that requires me to write an actual note, I chart as I go. Otherwise, assessments and things (where we just click boxes) usually wait until later.
- Sep 21, '12 by Nurse ABCThat's what we have too. Computer charting with tons of boxes to click on-same thing twice a day. It feels like it takes forever and it's such a pain!
- Sep 24, '12 by Quit Floating MeI usually manage to find time in the morning after I obtain vital signs and do assessments. However, recently the facility I work at changed the morning med times to 9am instead of 10am so now I have one hour less than I did. When I am not floated and I work on my floor I generally chart between 8:15am an 8:45am. On days we generally have 5 patients each with no CNA. However, when I am floated then I usually do my charting after my morning med pass around 10am or 11am~ish, depending on what happens. We use a computerized system but I always sit down to do my assessments and I do them all at one time. If any changes occur throughout the day I make a nurses note rather than re-do the whole assessment. (It wont let you target one system to document on, you have to do the WHOLE thing.)
- Sep 25, '12 by That GuyIts a tough question to answer. Everyone is different. Personally, I would rather see all my pts starting shift so I have a baseline of how they are before tackling meds, annoying family, getting them to bed etc. So what I did is the second side of my brains I would write down what I needed to remember and it was all short hand. Things like No N/V/D/HA/P +2p/CL/ABS. That basically worked out to no nausea vomiting diarrhea headache pain +2 pulses clear lungs and active bowel sounds. If there were more things that were off say neuros or wounds, I would write those down. That gave me the basis for my charting later. It worked very well for me on the floor.
I did preceptor newbies though and some did it my way, others did the chart as they went. It is how the person who preceptored me taught me and I liked how it flowed for the night. Try both out. See what works. So many things we do in nursing, come down to personal preference and what just works for you.