student nurse venting about paperwork

[bernikitty]

hi, i'm in my third semester of a five semester ADN program. i have really enjoyed nursing school and so far i'm doing well (knock on wood!!). one thing i'm really frustrated about is that no one is really teaching us how to do the paper work, ie charting, nurses notes, putting physical assessment in narrative form ect.

every instructor has a different set of expectations, and it seems that i spend alot of time trying to clarify what they want, because they are the one's who write down the grade. it doesn't help that most of our clinical instructors don't have any teaching experience, so IMHO, don't clearly communicate what they expect. and some just don't communicate at all and i guess i'm supposed to "psychically" figure out what they want. these instructors are the worst, because many times you are too scared to ask a question for fear it will reveal a knowledge deficit and the instructor will use it against you in your eval. what gets a passing grade with one teacher, looks like someone bled all over it, due to all the comments with another.

only one instructor, who was part time, went out of her way to furnish us with samples of narrative assessments and samples of charting to refer to and use as a guide. i was lucky to have her, but she is the exception, most of the time the instructors are just saying, "keep at it, i'll let you know when you get it right." but, i'm being graded so this hit or miss situation is really stressing me out.

on clinicals, alot of time i see, nurses spending the majority of time sitting at the nurses stations charting for all their worth, only to be annoyed when their charting is interrupted to provide patient care. this along with my experience in school had lead me to wonder, how many nurses really get out of school with the skills they need to document correctly, clearly and competently?

i'm seriously thinking of going to the director and asking why they can't standardize the paperwork, so we can spend five semesters perfecting this important skill, instead of feeling like we are starting over from zero every semester.

[BrandybunsRN]

I would be upset also if no one had taught me some of thebasics of charting. We learned the basics though in many of our papers or care plans we had to write. In all that information in the paper was subjective data, objective data, assessment and plan. (SOAP) Although when you chart on a patient in the hospital it is no where near as lengthy as a care plan.

However, this being said, there are so many variations in the kinds of charts that it would be difficult to show someone "the one way to chart". Hospitals vary using different EMR's or different paper charting. Some do charting by exception (where all you really write are any variances) and some do full charting (which means you write "WNL" for every section of charting you're doing. Some use flowsheets, and others require the nurse to chart in the progress notes.

There is no perfect way to chart. Instead, you have to use critical thinking skills and observation to see what other nurses are charting, what your facility does or does not require, and then go from there. If you are that unsure, maybe ask the nurse you are working with that day to review your charting and see if you made any mistakes or missed anything.

[OldNurseEducator]

I think it would be a good idea for you to go to the Director of the program. Perhaps she or he is unaware of the problem with instructors not declaring their individual expectations. Their expectations should be in writing and given to the students. I understand how this can be very frustrating for students. Just my .

[apocatastasis]

I was just talking about this to my NP classmates. Except we were talking about how ridiculous it was that they made us paper chart everything... which nobody does anymore.

Ok, a bit of an exaggeration, but you are likely to be using computer charting, which you'll have to be oriented to at your facility. The skills and observations are the most important thing.

[EDnursetobe]

the hard part about teaching charting is that each hospital system does it differently.

which is why in nursing school they want you to get the basics down first.

also, I know I learned more about charting while doing my preceptorship. do you have that? or an internship of some kind? that's a good time to practice.

[Anderle]

Thanks for bringing this up.I am a new grad. I think you should mention this to your director. We did many clinicals in hospitals that had computerized charting. We'd chart by checking WNL or NWNL (not within normal limits) then if NWNL you'd be prompted to another screen to just check more boxes (no writing). Seldom did we write more than a sentence or two. Then in our last semester during psych, our instructor was really into documentation and all the students realized that we should have learned and practiced this right from the first semester. Students were writing too colorfully or writing too much or just stressed and shut down because we were not proficient in effective charting. Less care plans and more documentation would have been better.

If I end up working in a non-computerized facility, I feel I will be embarrassed by my charting.

[muesli]

Charting varies greatly from hospital to hospital. As a nursing student, focus on performing a thorough head to toe assessment and writing down your findings, lab values, etc. system by system. Most of the documentation I've had experience with has been system-specific (i.e. integumentary, nutrition, activity, cardiovascular, respiratory, etc.). Experience making care plans are very helpful. While most care plans are generated with very little effort by the nurse using computer technology, the associated interventions specific to certain conditions and systems are what you will be documenting that you completed in your note.

In my work, we do a lot of double documenting. We document a change of shift note which is organized system by system. We then fill out a shift assessment that also goes system by system with canned answers (for example, under the cardiovascular system, does this patient have edema y/n, is heart rate regular y/n). Then we document every shift that we did some standard nursing interventions, including ostomy care, peri care, teaching etc. It sounds complicated but you'll get the hang of it during your orientation and will soon be sick of all the double documenting!

[ayorenee]

I truly learned how to chart once I started on the floor. In nursing school it was care plans galore, and each hospital or clinic that we rotated at had different systems for charting.

[mghammond82]

http://www.amazon.com/Charting-Made-Incredibly-Easy/dp/1605471968/ref=sr_1_3?ie=UTF8&qid=1319783398&sr=8-3

Get that book, it has been a life saver for me. It helped me in school as well as out of school.

[xtxrn, ASN, RN]

Agree with getting general information from one of the charting books- Charting Made Easy is good. Any of the Incredibly Easy books are helpful. Each hospital/facility has their own system and often different software programs. But at least the books will give you a clue :)

[highlandlass1592, BSN, RN]

Agree with getting general information from one of the charting books- Charting Made Easy is good. Any of the Incredibly Easy books are helpful. Each hospital/facility has their own system and often different software programs. But at least the books will give you a clue :)

Hey xtxrn: here's the source for your quote, Henry Ford said it.

http://quoteworld.org/quotes/4834

Just thought I'd share. Have a good one

[xtxrn, ASN, RN]

Hey xtxrn: here's the source for your quote, Henry Ford said it.

http://quoteworld.org/quotes/4834

Just thought I'd share. Have a good one

Hey, thanks :) I'll update