Are you good at charting in "real time?"

  1. 0
    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!

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  2. 35 Comments...

  3. 1
    Sometimes I am and sometimes I am not. It depends on what is going on at that time but my goal is to chart as close to time as possible. It is hard to do when short staffed and getting admission or post OP patients early in the shift. If I have 6 patients and no patient tech, I can guarantee much of the charting will be behind.

    I try to do a quick assessment progress note and complete the quicker charting such as fall risk and IV lines leaving the body assessment last. Sometimes i do the reverse.
    Ativan likes this.
  4. 3
    I'm in the ER so I have to chart in real time because I never know when assignments are going to be switched or when I go on break, etc. I've found that using the computers in the room help, especially with the assessment. I can ask all the questions as I chart. Then I just make sure to write a quick note every time I go in the pt room and I'm all set. I'm sure it's different on the floor, but that's my trick in the ER. If we charted hours later the pt would already be discharged!!

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    Ativan, emtb2rn, and Emergent like this.
  5. 1
    I'm still but a student, however I at least get the VS done and charted in as near real-time as possible. Then once I've got a few minutes, I then chart the "faster" items and then the assessment. Somewhere in there, I'll put in an assessment note.
    Ativan likes this.
  6. 2
    I am not one of those nurses you will see drifting in a few minutes late and dragging their feet getting their work started.
    I find that for me, really pushing through the beginning of the shift gets my day of to a good start and I can keep up with the charting better if the first round of charting, assessments and meds are done efficiently.
    I like to chart in the patient room if it is quiet and there are no visitors. The nurses station has more distractions.
    There is only so far you can take things. Patient care comes first. These days there is a bigger link to reimbursement in computerized charting, so expect a push towards nursing the charting.
    Ativan and Twinmom06 like this.
  7. 1
    I'm in the ER and I try to. I try to do a quick patient rounding, quick charting atleast a little blurb.

    Lately with staffing at an all time low and patient volume at an all time high I feel like I can never catch up on my chart. I'm actually DOING stuff, just so busy that charting is my last priority. CYA always prevails though... I try to atleast go back and finialize my charts on very critical patients.
    Ativan likes this.
  8. 10
    I the ED it is the nature for real time charting. In other units it is not so easy. I would fail miserably at this. I ALWAYS put off charting until patient care was finished.

    I am so NOT into this real time charting. I think it removes the nurses attention away from the patient to the computer.. And they wonder why patients complain.
    Ativan, Dazglue, RNinIN, and 7 others like this.
  9. 5
    I felt the most efficient way to chart was at the bedside. I would enter my assessment as I was performing it. Actually gave me a little more time with the patient and I couldn't forget any details.
    cjward3, Ativan, RNKPCE, and 2 others like this.
  10. 3
    I will update the vitals, hourly urine outputs, and document any call I made to anyone including physicians/pharmacy/lab and their responses as close to real time as possible, but that's it. I will do the assessments in real time if I can, but usually they are getting done later in the shift. Patient care comes first.
    Ativan, RNKPCE, and Wise Woman RN like this.
  11. 1
    I'm usually good at getting my frequent things in--neuro checks, VS, pain, hygeine/positioning etc.

    I also like to enter the skin assessments on our multiple traumas at the bedside, since I don't always trust my memory at 4 a.m....which humerus was ORIF'ed and which still has the ex fixes on? Which wounds are uncovered, and what type of dressings are on the others? Where all do they have lacerations, bruising? What amount of type of drainage do they have from all these wounds? You get the idea.

    The full assessment usually gets entered at least 2-3 hrs into my shift; we do NOT chart by exception, and our form is really long. So if I enter it all right at the beginning, my other pt is kept waiting. (I imagine this is much more of an issue on the floors, where they get 6-7 pts on the noc shift.)
    Ativan likes this.

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