No time to review patient charts

  1. I need some suggestions. We do not get the luxury of having time to review are patient charts prior to being assigned to our patients. Essentially we show up 1/2 hour early with our instructor and he assigns the patients to us. My last clinical instructor gave us patient history/dx/meds the night before so we were able to really put a lot of research into our daily planning for the patient. This other way really has me frustrated because literally we are off running the minute we get there. We are not allowed to go in early as the instructor won't, therefore, it kinda leaves us (the group)feeling ill prepared alot of times, and frankly, causes anxiety the night before clinical. The instructor said that this is what happens in real life, that in real situations you might not get time to look up patient information, especially when you have 4 or 5 patients that you have never seen. I feel that in some ways this is a real disadvantage for the students. Many time I have looked up info the night I get home from the hospital on my patient only to find out the next morning the patient has been switched. I've bought a pocket size Med/Surg book which is ok, but I still don't have my drug books (the ones on the ward are old and falling apart), or my other nursing books that I usually refer to. Does anyone have any advice how I get more prepared in this type of situation?
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  2. 24 Comments

  3. by   Jen2
    We must go to the hospital the evening before and start our careplans, otherwise we cannot care for the patient if we do not have it mapped out. In your case I would probably go to the primary nurse that is in charge of that patient and get report first. I can see where that would be tough Good luck.
  4. by   newgrad2004
    We take our own drug books with us to clinical. I have a clip board that has an area that is underneath to store this book along with my papers. As far as being organized, or preparing you cant in the real world, so basically when you get there, after report, go to each pt's chart after vitals or if a cna does them let her/him, and go look up the h&p and dr's orders, then go about your assessment, or if you have no time look after your assessment. You usually have a couple hours before the majority of the meds need to be given, and baths are not until after breakfast. Also if your pt can help themselves it is ok to set them up to bathe themselves and tell them if they need help you can come back and assist in areas they cant get to. From what I have learned, each patient and bath or other duties will not be on time all the time. If your running behind on patient care then ask for assistance or tell your nurse, or aid so. Prioritize your patients needs, and get the meds on time. Get help from the aids or other students if you can, or the nurse. If you have down time help other students, aids, or nurses, they usually will return the favor.

    Good luck !!

    I know at times it seems the day will never end. But it does.


    Quote from joey1967
    I need some suggestions. We do not get the luxury of having time to review are patient charts prior to being assigned to our patients. Essentially we show up 1/2 hour early with our instructor and he assigns the patients to us. My last clinical instructor gave us patient history/dx/meds the night before so we were able to really put a lot of research into our daily planning for the patient. This other way really has me frustrated because literally we are off running the minute we get there. We are not allowed to go in early as the instructor won't, therefore, it kinda leaves us (the group)feeling ill prepared alot of times, and frankly, causes anxiety the night before clinical. The instructor said that this is what happens in real life, that in real situations you might not get time to look up patient information, especially when you have 4 or 5 patients that you have never seen. I feel that in some ways this is a real disadvantage for the students. Many time I have looked up info the night I get home from the hospital on my patient only to find out the next morning the patient has been switched. I've bought a pocket size Med/Surg book which is ok, but I still don't have my drug books (the ones on the ward are old and falling apart), or my other nursing books that I usually refer to. Does anyone have any advice how I get more prepared in this type of situation?
    Last edit by newgrad2004 on Mar 19, '04
  5. by   Carolanne
    I think this is a pretty common scenario. We don't get to really read the charts either until we have some free time later on in the shift. We get our assignment from the instructor, look at the cardex for our pt. at the nurse's station which pretty much hits the hot spots on what we need to know to get started (age, diagnosis, diet, how they ambulate, tests/ labs, one touches, etc.). Then we can meander over to the medication book on the med cart in the hallway and glance over what meds they're on and note if any IV's are in the future, etc. And of course, if you listen to report from the change in shift, you can get quite a bit of info from that too. So just gather up what you can to get things rolling and you'll do fine.
  6. by   VivaLasViejas
    This is actually great preparation for real-life nursing, where you have about 15 minutes to gather all your info on your six patients for the shift.

    When I was in school, however, we didn't get thrown to the wolves like this until our last term, by which time we were all so sick of writing care plans for pts who inevitably had been discharged the night before clinical, that we relished jumping in there without 3 hours of prep work. Now sometimes I wish I had the luxury of reading over an entire chart and making notes before trying to care for someone with multiple medical/psychosocial issues...........
  7. by   joey1967
    Quote from Carolanne
    I think this is a pretty common scenario. We don't get to really read the charts either until we have some free time later on in the shift. We get our assignment from the instructor, look at the cardex for our pt. at the nurse's station which pretty much hits the hot spots on what we need to know to get started (age, diagnosis, diet, how they ambulate, tests/ labs, one touches, etc.). Then we can meander over to the medication book on the med cart in the hallway and glance over what meds they're on and note if any IV's are in the future, etc. And of course, if you listen to report from the change in shift, you can get quite a bit of info from that too. So just gather up what you can to get things rolling and you'll do fine.
    Cardex is a great suggestion! I totally forgot about it, usually the unit clerk has it in her hot little possession and in front of her. One primary did point it out to me a couple of weeks ago, but it totally slipped my mind. Thanks for the suggestion!
  8. by   RNsweetie
    we are required to go in the night before and research our pt's and come fully prepaired. one of my instructors had us come in one clinical day "cold" as she put it.
    It was great preperation for the real world but I do feel that if I dont research now, I won't be as prepaired for when I am a "real" nurse.

    Good luck..
    Erin
  9. by   jenrninmi
    Quote from joey1967
    I need some suggestions. We do not get the luxury of having time to review are patient charts prior to being assigned to our patients. Essentially we show up 1/2 hour early with our instructor and he assigns the patients to us.
    That's how ours was too. I liked it that way though. Although ours was Maternal/Child. We got report from the midnight nurse like the nurses we were following did. I'm only assuming it will be like that in the rest of my rotations, but I'm not sure. Having to go in the night before to pick my patient does not sound like something I'd like to do. I'll have to see though. It may be different once I get into Med/surg.
  10. by   Coldfoot
    If you can aford it, a PDA might help. You can get Epocrates (sp) free and buy several referance books. Then they all fit in a pocket. Just and idea.
  11. by   kahumai
    I'm in my second semester of clinicals, and we aren't allowed to go on the night before to research the patient because we are only allowed on the floor when the instructor is there. We have to be there by 6:30 am, but luckily our instructor gets there at 5:30. I usually show up at 5:45 am and from that time until 7:00 am I STILL don't have enough time to write down all of the labs, meds, etc, etc, etc. We write up our paperwork, care plan, nursing dxs, etc, the week after. Kind of backwards, but what can you do???

    I would say just try to write fast and know what the most pertinant information is and how to find it fast.
  12. by   wonderbee
    We do it the same way. We don't even get up to the floor till well after report is given. We're always a step behind. What I hate is preparing the care plan after the clinical experience is over. It would be nice to have the luxury to be able to evaluate your results but since we see the pt., then go home and write the care plan, it's tough to fill in that blank about the results of our implementations.

    Because of day care concerns, the earliest we can get to the hospital is 7:30. Our school is very sensitive to the needs of parents with small kids. Unfortunately, by the time we're finished getting our pt. assignments, we get to the floor about an hour after report has been given. The nurses on the floor resent having to give the students a second report.
  13. by   Brickman
    I never go the night before even though that option is available. I look at my patients diagnoses,meds, and check the orders when I get on the floor. Our instructors allow this because it better prepares us for the real world where no one will be getting their assignment the night before. It may seem difficult at first but after awhile you will love not going the night before.
  14. by   LeesieBug
    Wow, I didn't know there were schools that did it that way. At least not in the beginning levels. It's always interesting to hear how other schools do things.

    I spend about six hours the night before clinical doing the required paperwork. Most of the clients have fifteen to twenty meds we have to look up and fill out information on. When we get to clinical, we spend pre-conference discussing our clients health issues and what interventions we are going to be doing, problems we should be on the alert for, etc.


    If I had to be ready to give care without that preparation, which at this level I do not feel would be a good idea (2nd semester), I agree that the Kardex would be my best friend!!!

    Hang in there!

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