I have some questions about charting...

  1. 0
    I started my nursing career in a facility with computerized charting and I was very diligent at charting. I charted often and very detailed.

    Now I work at a unit where there is paper charting. The way that the charting is done is the there is a complete beginning of shift assessment that is charted, along with goals for the shift (maintain safety, pain control, etc.) Then at the end of the shift there is an evaluation charting stating what the patient did during the day such as ambulated in hall, dressing change, pain control measures and if the goals were met.

    This style of charting is more recap of what happened rather than the previous method of charting at the precise moment that the events occured.

    One example of the difference is neuro checks- previously I would chart every two hours as ordered about my findings regardless if there were changes. Now we are taught to chart at the end of the shift that the neuro checks were completed every two hours with no changes.

    The same for IV checks.

    Is this an acceptable way to chart?
    Is it wrong to be too detailed with charting... I have heard arguments for this.

    I have a real desire to perfect my charting and to make it detailed and at the same time not overwhelm my shift and prevent me from giving quality care.

    Thanks for your advice.
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  4. 2 Comments so far...

  5. 0
    What is preventing you from charting during the day?? I worked w/ computerized charting...which I love..and then switched to paper charting...I still document in real time...that means if I did a dressing change or the pt ambulated I record it as soon as possible..otherwise I can forget details


    Quote from Nellie Nurse
    I started my nursing career in a facility with computerized charting and I was very diligent at charting. I charted often and very detailed.

    Now I work at a unit where there is paper charting. The way that the charting is done is the there is a complete beginning of shift assessment that is charted, along with goals for the shift (maintain safety, pain control, etc.) Then at the end of the shift there is an evaluation charting stating what the patient did during the day such as ambulated in hall, dressing change, pain control measures and if the goals were met.

    This style of charting is more recap of what happened rather than the previous method of charting at the precise moment that the events occured.

    One example of the difference is neuro checks- previously I would chart every two hours as ordered about my findings regardless if there were changes. Now we are taught to chart at the end of the shift that the neuro checks were completed every two hours with no changes.

    The same for IV checks.

    Is this an acceptable way to chart?
    Is it wrong to be too detailed with charting... I have heard arguments for this.

    I have a real desire to perfect my charting and to make it detailed and at the same time not overwhelm my shift and prevent me from giving quality care.

    Thanks for your advice.
  6. 0
    Quote from DUCKGIRL
    What is preventing you from charting during the day?? I worked w/ computerized charting...which I love..and then switched to paper charting...I still document in real time...that means if I did a dressing change or the pt ambulated I record it as soon as possible..otherwise I can forget details
    There is nothing that is preventing me from charting in real time. This is just the way that I was instructed to chart at this particular institution and I am wondering if this is acceptable or if I should continue with what I was doing before.


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