Charting patient turns???

Specialties Med-Surg

Published

Specializes in Postpartum.

I just started on med/surg and am a new grad. All through school and orientation we were taught "charting by exception". Yesterday we got an email from the mgr stating "I noticed patients being turned are not being charted. If its not charted it didn't happen". ????? I have not heard of having to chart a patient turn every two hours other than if they are restrained.

We have 20-25 pts on nights and sometimes only one aid. We have turn clocks for the door if they are full care. Is this another thing to add to my already overwhelming list of things to remember to chart????

Or did I miss something?

Up Vote Up Vote ×
Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

This is where charting irritates me. They tell you to chart by exception and come up with exceptions.

If you have a "care plan" that states they are to be turned q2h, then you're covered. For example on our "Skin Care Protocol", it states they are turned q2h and no need to document it.

You might be the new kid on the block, but check with your educator and then inform your manager that you are covered by the care plan, if you have one.

Up Vote Up Vote ×
Specializes in ER.

Agree with Tweety (as always).

Up Vote Up Vote ×

is your charting system truly a charting by exception system??? or is it one of the ones I call the noncharting system??? I've worked with good systems and horrible ones. The one piece of advice is have is...when in doubt, chart it....meaning CYA!

Up Vote Up Vote ×
+ Add a Comment