nursing documentation

  1. Its been a month now since I started with my orientation and my preceptor is slowly letting me go on my own...but I feel so unsure at most times with what Im supposed to do...Im good with establishing rapport with my patients and their families but I feel that I have to learn more as far as their care and cases are concern...I see my preceptor answer all their concerns and questions spontaneously..I wish I can do that too...

    I feel tense and nervous each day that I go to work not knowing what cases I will be facing each time...And at the end of the shift,
    I keep on thinking back if I have done all the things that Im supposed to do..documented and all...plus I have this problem also with writing the nurses notes...I am not sure at times if I have properly worded it (legally safe and all..)

    Dont get me wrong..I like learning things..I guess I just want to vent out my feelings of ...inadequacy...that somehow, later on I will be good with what I do..coz right now I know that I have a long way to go..and lots to learn..

    Did any of you feel this way too when you were just starting with nursing?
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  2. 10 Comments

  3. by   baseline
    Yep. And I'd be worried about you if you weren't nervous and worried about your skills. I am sure you are going to be fine....but nothing will give you confidence like experience. You have go out there and just DO IT!!! Good luck!
  4. by   Gardengal
    Most new nurses (Me included)felt that way when they first started out. What's really scary is when people think they know everything and don't voice their concerns. That tense and nervous feeling will get better as time goes on.

    I always recommend to new people to find at least one good thing that they did each day, and remember that. At the end of a week I ask new nurses to look at what they felt were strengths and then at an area on which they should concentrate the next week. If you pull these evaluative sheets out after a couple of months you'll be surprized at how much more comfortable you are with many things.
  5. by   blue280
    Boy, can I identify! I am a newbie nurse and am getting inpatient to be at ease like I see the other nurses are. How long does it take? My biggest problem is trying to get all my work done in my shift. Does any one else have to stay over to get it all done?
  6. by   Chicklet
    I feel that I am all left thumbs right now and also we have
    a Pixis to distribute our meds, and Im sure that I will get it, but
    to go through a computer to get your meds, I think I would
    rather use a gun, it would be faster...only kidding.
  7. by   deespoohbear
    Originally posted by DARN MOM 128
    Boy, can I identify! I am a newbie nurse and am getting inpatient to be at ease like I see the other nurses are. How long does it take? My biggest problem is trying to get all my work done in my shift. Does any one else have to stay over to get it all done?

    When I was a new nurse, I always seemed to be the last one out the door. Then I took a good hard look at my documentation and the way I was organizing my shift. Try "to kill two birds with one stone" as often as possible. Are there certain tasks you can do in one trip? When I get a new admission I try to glean as much information as I can. By just speaking with them I can usually assess their mental status, their speech, their body language. If I am helping them get their shoes off I can assess for edema and pedal pulses. I can assess their skin turgor and color at that time. Whatever tasks you can do safely at one time, do it. Make conversation with them. Ask them what brought them to the hospital, what kind of meds they are on and what they have taken so far for that day. In the first 5 minutes or so, I can already have a wealth of knowledge about my patient to record on the assessment sheet. Watch some of the more experienced nurses on the floor to see how they get stuff done. (Just make sure they are not jeopardizing patient safety/care in the name of speed).

    You will eventually build up confidence and speed. I know it probably took me a good year before I felt like I knew most of the ropes of med-surg nursing. And I still get curve balls thrown at me (and I have been a Med-Surg nurse for over 8 years) to give me a reality check occasionally.
  8. by   rachel h
    I know how you feel! I've been at it almost a year now and it took me about 6 months to be comfortable...

    As far as wondering if you've documented, etc. develop a system with your worksheet. For example, the main things I need to remember are 1) sign my MARS and flowsheet, 2) Assess my patient, 3) complete my flowsheet (I&Os, etc), 4) write my note, and last but not least, 5) my 8hr chart check. Your facility may be different, but I incorporate these things onto my worksheet and check them off as I finish them. It really helps a lot at the end of the night when I can just look at my worksheet and see that I have checked everyone off.

    I just write SS (sign sheets), A (assessment), FS (flowsheet), N (nurse's note), and 8hr (chart check) on my sheet and cross them off as I finish.

    As far as notes go, just remember to remain OBJECTIVE. I find a SOAP note is easiest (although I hated them in school!). I suppose it depends on what your facility allows, though.

    It will come with time, don't worry. Good Luck!
  9. by   momangel29
    I feel inadequate constantly!! Being a new RN since February there are so many obstacles to overcome but every day I go back and try harder.Nothing in life is worth anything unless you work hard for it.
  10. by   meownsmile
    Yep,, sounds pretty status quo to me too. Been there done that, and still do sometimes, it gets better. After you are on your own and you establish your own routine you will feel much better.
    Welcome to nursing!!!
  11. by   altomga
    [QUOTE]Originally posted by avolensky
    [B...I see my preceptor answer all their concerns and questions spontaneously..I wish I can do that too...

    you sound like a typical newbie....this comes with time...and essentially practice....
    being nervous, concerned, etc is to me GREAT qualities in a new nurse....it shows me they care about what they are doing.
    Even after all these years..a pt/family member may ask me a question and I will have to say..."I'm not sure..let me go check on that...or find the answer" something to that effect.

    You can't know everything, and sometimes we have brain "farts"
    the confidence though will come....

    Take care and good luck...happy to know we have yet one more empathetic nurse aboard
  12. by   Jliza888
    i have been on the med/surge floor now for 8 months and with guts and glory under my belt i am now a charge nurse...i came into this just like all you guys, scared stiff, but that will all go away when you remember that you are a patient's advocate and that they need you to be there and assess thier needs, the doctors need you to be their eyes, and investigate the treatment at hand if it is effective for the patient or not...there are so many things we are called to do...now i don't have a single butterfly in my stomach because i feel needed! all nurses are well needed...the sooner you get rid of that new feeling the sooner you'll realise that you are flying high with the challenges at hand and proud to be your patient's advocate!
    Last edit by Jliza888 on May 28, '03

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