charting phobia

anyone have any tips on charting, its my biggest problem, I know I'm gonna make a great LPN(I really enjoy taking care of pt's), but I am hopeless at charting!!!!!! any advice, tips, books on charting would be soooo appreciated :}

I can tell you that charting is your greatest friend and guardian against liability. Let me tell you my little story:

I'm an LPN in FL. The nursing instructor I respected the most, who was also a real stickler for charting, drummed it into our heads: CYA (cover your ass-ets) and chart as much as humanly possible, and THEN some, espcially if you have a problem with your supervisor not listening to your concerns about a patient, which is what happened to me one day.

The RN thought she was the only busy one there that day, but I saw that I had a patient that was taking a turn for the worse. I told her he was taking a turn for the worse, then watched to see if she came to look in on him. She didn't. I kept going back to tell her, each time more urgent than the last--still she wouldn't check on him. I'll give you an abbreviated account of my charting that day, leaving out the medical bits because that would be too long:

12/02/2000 1300 hrs: ...advised RN NeverListens.
12/02/2000 1315 hrs: ...advised RN NeverListens.
12/02/2000 1300 hrs: ...advised RN NeverListens.
12/02/2000 1325 hrs: ...advised RN NeverListens.
12/02/2000 1330 hrs: ...advised RN NeverListens.
12/02/2000 1335 hrs: ...advised RN NeverListens.

By 1335, I was at the patient's bedside as he coded, luckily. The call light wasn't working of course, nor was the intercom that was connected to it, so I had to run out into the hall and yell for her & others to come, after I called in the code.

The RN comes in and was immediately looking to pin everything on me. The crash team was there working on the patient, was able to save him, and all the while the RN was doing everything she could verbally to make me look like the one who had neglected him. She even said I ruined precious seconds because I didn't pull the call light out of the wall, which makes the emergency light blink, for pete's sake!

Remember how we are instructed to keep out of the crash team's way when they arrive, unless there are tasks you can do, or they ask for help? During that time, I had already charted the above about the light being broken, and calling the code @ such & such hours, and what I had done to help the patient. The crash team, listening to this RN, frowned at me and picked up the patient's chart right before the RN grabbed it, and there was nothing she could do to back up her lies because I had already charted everything right above the notes the crash team had added.

She was busted, my career & good name was safe, and most importantly, the patient was safe.

Maybe he was better off she had not looked in on him, because I looked after him with an even closer eye.

I'm not saying every RN is bad, heavens no! I am saying that you will definitely have co-workers and supervisors who will send you up the river if you aren't careful, so chart-chart-chart, especially on the dangerously ill patients...I know it is more of a challenge now than ever before.

I probably won't remember to check back here for messages on my post, because since then I've contracted a neuro disease that left my career behind me as my short term & long-term memory became hampered, so please don't think I'm ignoring you if I do not answer. I just wanted to tell this to you, so you keep it in mind in case you end up with a similar situation...and chances are too good that you will!

-Cyndi

Missy...
She charted Notified RN "neverlistens" .... neverlistens as being the rn's name...lol
To the original poster:

The Nursing made Incredibly easy... book series has a book about charting which is really good and I recommennd to many of the graduate nurses that hit our doors.....
It's .... Charting made incredibly easy...

Missy's advise about AIR ... it is very good advise....

Missy...
She charted Notified RN "neverlistens" .... neverlistens as being the rn's name...lol
To the original poster:

The Nursing made Incredibly easy... book series has a book about charting which is really good and I recommennd to many of the graduate nurses that hit our doors.....
It's .... Charting made incredibly easy...

Missy's advise about AIR ... it is very good advise....