Need help with charting and time management

  1. I'm in my second semester of my junior year, and I feel thrown to the wolves in regards to charting. We've never been taught but we're expected. The hospital that I'm currently doing clinicals charts by exception. I know that I have to chart my assessment on the nurses notes, but does anyone know where else I might need to chart? Anyone have any suggestions for books or web sites. I just feel so uncomfortable with it. Also, time management is a problem for me. I feel like I don't have the time to chart. I know that's not a new complaint, but does anyone have a good routine that works for them?
    Thanks, I feel very discouraged right now. I feel pretty confident with patient care, but I know I need to feel confident with the charting also.
    Maggie
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  2. 5 Comments

  3. by   TweetiePieRN
    If you want, I can give you an outline of what was given to us by our nursing instructors. It is a time management outline. It works pretty well so far. Granted, I am only a student also, but I showed it to other nurses and they said that it is a good way to organize your time. PM me and let me know! Oh, I just remembered, I do have some charting tips for you also. PM me when you can.
  4. by   SCNuttyMeg
    There is a charting book by Made Incredibly Easy that I bought to help me with my charting. (it didnt help too much though). Im a new nurse and struggle with the charting portion. I only chart by exception. We have a flowsheet you use for your assessment and if they have a cough but its not on the flowsheet, I right it in near the lung section. In my narrative notes I always put how i found patient whree oob to chair legs elevated etc and I always put assessment per flowsheet. Or assessment complete see flowsheet. We have pictures of the body on our sheets and if a patient has a bruise or a dsg i mark the area and write out beside what i see.

    Now when to chart is another iffy topic. Some nurses can chart at the end of the shift, but i tend to forget(dont let your instructors see you do that)My instructors wanted you to chart after each patient. In the real world i take a sheet a paper make 5 boxes and put the abnormals in the box so when i chart i remember. Or if i give pain med i write the time pain scale in that box so when i see all my patients then i chart.

    Good Luck
  5. by   coulterd
    I feel the same way. I am having problems with charting and time management. I would appriciate any info you have recieved on it.
    Thanks,
    Debbie

    Quote from MaggieJo
    I'm in my second semester of my junior year, and I feel thrown to the wolves in regards to charting. We've never been taught but we're expected. The hospital that I'm currently doing clinicals charts by exception. I know that I have to chart my assessment on the nurses notes, but does anyone know where else I might need to chart? Anyone have any suggestions for books or web sites. I just feel so uncomfortable with it. Also, time management is a problem for me. I feel like I don't have the time to chart. I know that's not a new complaint, but does anyone have a good routine that works for them?
    Thanks, I feel very discouraged right now. I feel pretty confident with patient care, but I know I need to feel confident with the charting also.
    Maggie
  6. by   iiwdn
    I've been at this game for 15 years as an RN now-- 9 years as a NAC before that.
    School is a great place to get the theory of it figured out but when I found myself the real world I relied on staff nurses that seemed to have it down (be careful who you choose to learn from in all regards). There is an art to it -- just like the rest of nursing, therefore it has to be practiced, and changed, and practiced some more. I am sure that if I had the opportunity to go back and look at my early charting attempts I woudl be appalled both at what I chose to included and what I excluded.
    It's kinda like the old question "do I look at the patient first or the chart?" Well it depends... prioritize and plan and be flexible! You can do it. Sounds like your well on your way.
  7. by   Jennerizer
    That Charting Made Incredibly Easy is a waste of money. I have one, it doesn't help at all. In second semester I had trouble keeping up with the charting, but now in third semester we were told to chart something at least every 2 hours in the nurse's notes.

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