Are you good at charting in "real time?"

[Ativan]

Are you good at charting/documenting in "real time," that is getting your assessments and vitals charted close to the time you actually do them instead of catching up with charting hours later at the nursing station? Any tips for how to do this successfully without delaying the rest of your care? Are you faster at documenting than all your co-workers, and if so, any tips?

Our hospital is pushing nurses to start documenting closer to real-time because the charting will be linked to patient acuity. I'm curious to see if this is actually humanely possible; looking for examples of nurses who successfully do this.

Thanks for any advice/opinions you might have!

[RNKPCE]

My goals is to do every assessment in real time but reality is another story. I may get my first patient done but then my while assessing and charting on my second patient one of my bed alarms goes off and well you know………you have to toilet the bed alarm patient and then ER is calling report on your new admit………. My intention is to do it all in real time but not at the risk of patient safety or causing a problem with throughput.

[ArtClassRN, ADN, RN]

Are you good at charting/documenting in "real time,"

No. I'm pretty good at taking care of patients in real time though.

[UnbrokenRN09, BSN]

Real time charting just isn't very realistic unless you have a computer at the bedside. Depending on how complex your charting system works, it may not be time efficient even if one is available. If there's umpteen million "normals" to click on that takes time. If you have a lot of incision assessments to chart, that takes time. I chart mostly in real time at one of my jobs, because we chart by exception, the format is very easy and i can buzz through an assessment form in just a couple of minutes, as I'm talking with the pt and asking questions. If there is a lot of abnormal stuff to chart and it will interfere with my workflow too much, I'll simply chart what I can quickly, save the form and finish it later, that way it still shows that I charted in "real time". My other job....yeah it just doesn't happen. I have to jot down my assessment in my special little notations I came up with, and may not sit down to chart until midnight. I have access to a computer at all times, but everything is set up in a flowsheet format and it's too tedious to scroll and click 50 bajillion boxes...It would be 2200 or later before I got to my last patient, then it'd almost be time to start round 2. This just doesn't work, especially since the nurses are required to do the VS on that floor as well. It just wouldn't make sense to run to all the rooms and do VS, then back again for meds & assessments.

Personally, I prefer to chart in real time as I go, but it's not really feasible to do it quickly unless you chart by exception. It's always seemed pointless to me to chart all the normal crap. I mean they're in the hospital d/t the abnormal things right?? Why do i need to waste precious time charting cap refill less than 2 sec, pink, pink, pink, pink, moist, "normal" ( yes some sections actually have this as an option), present, clear, yellow, etc etc etc. It's dumb!!!

[EmeryRN]

My floor has been pushing for real time charting, and if I has a few pts, I sometimes do. But by the time I make my rounds and answer questions from the pts, fam, MDs, I need to do meds. Especially if I get vitals that need to be addressed right away. I work overnights and ppl want to sleep and I want to spend time w all of my patients and find out if I need to call for new orders before it gets late.

And also if there's a more critical situation to deal with, that obviously takes priority. I try to document SOMETHING but I usually have most documentation to do later on. I'd like to document real time. I did before we switched over to a different system. But now I always care my report sheets and at least write things down

[BrandonLPN, LPN]

Are you good at charting/documenting in "real time,"

No. I'm pretty good at taking care of patients in real time though.

Don't you know by now that they care more about charting that a task is done than they do about whether or not the task was actually done?

[chrisrn24]

I work NOCs. I usually draft a note by 0200 and then edit it at the end of the shift. So sorta in real time sorta not.

[whichone'spink, BSN, RN]

I chart vitals and I/Os in real time but assessments I don't. Frankly, I don't want to get sucked into a patient's room for a long period of time. When I get the first set of vitals, I introduce myself, quickly do my assessment and then move onto the next patient. That way I see all my 4-5 patients before 0900 or 2100.

[Ativan]

Lots of great responses, thanks everyone!

It's interesting that there is a big split between nurses who think charting at the bedside is the fastest and those that are against it (either because it's distressing to the patient or takes too much time).

I also notice that nurses who are best at charting in "real time" seem to be those that view it as a high priority up there near patient care. I admit, this attitude doesn't come naturally to me, but might be an important mental shift.

I've done ED nursing and floor nursing, and the thing I miss about ED is that things get done in the order of what's most important and urgent, not arbitrary deadlines like "9:00 meds." So (unless there is a really serious situation) you can do, chart, do, chart, and not worry about late meds or getting your Braden score documented by a certain time of day or whatever.

[EmeryRN]

I've done ED nursing and floor nursing, and the thing I miss about ED is that things get done in the order of what's most important and urgent, not arbitrary deadlines like "9:00 meds." So (unless there is a really serious situation) you can do, chart, do, chart, and not worry about late meds or getting your Braden score documented by a certain time of day or whatever.

We still work based on priority but have to factor in giving meds on time. I work nights so my patients need to sleep and I need to do my chart checks and try and make calls before it's late. And more procedures are done during dayshift, so the patient may be gone part of the room. And if they need to be prepped for something, all takes time (and prioritizing). But on top of that, you have bed alarms, an incontinent patient to clean, family, etc. I do agree with you that those who do it more, rank it higher, and I wish I had time, but it's difficult. And not to start anything with the ED staff, but I always have some sort of mess to clean when I receive patients from the ED, but that's more likely my particular facility.

[Ruby Vee, BSN]

Using the bedside computer helps to get initial assessments entered in real time. Vital signs, I & O, medications, etc. are all entered using the bedside computer in real time. Notes, though, wait until I have a moment to sit down outside the room and gather my thoughts. It's difficult to do that in the room, especially with chatty visitors!

[BSNbeauty, BSN, RN]

I work on a busy post-partum floor. I usually try to chart my assessments as I go along. I've found that charting on 6-10 patients at once can be a bit overwhelming and things tend to get missed. When I chart on my patients one at at time, it gives me the insight I need to plan interventions during the day and follow up as needed. I also feel better when my charting is done right away just in case I get an admission or having an emergency at least I'm all caught up on my charting.

[SunDazed, BSN, RN]

I'm not a fan of real time charting .. but I am at the same time. I'm not because feel like the patient thinks I care more about the computer than them. However, when it comes to time management, it's glorious because you're constantly caught up.

And if I'm in a rush, what I'll do is quickly chart my abnormals in my assessments and go back later to chart those things that never change. That way, I'm always accurate and on time.

Real time charting can slightly hinder patient-nurse relationships (in my humble opinion), however it is GREAT for time management. There's no "wait.. when did I do that?

I agree with a lot of this post. My goal is to chart real time as much as possible. I am in short stay and each of us can get 3 new admits in quick succession... and it is easy to get them confused in your brain if they had similar procedures. I often make sure to enter at least a few things in real time as time marks for finishing up the other charting with an accurate time frame... especially if giving prn's for nausea, pain... the meds are always charted real time... but in the assessment charting change due to meds... under GI the nausea or I/O the amount of emesis... then following up to show improvement under GI again.

I feel bad charting at the bedside sometimes... because it often actually means my back is to the patient since the computers are on wheels and not mounted in the rooms. Some of my coworkers hang out in the doorways of the patient rooms, on the other side of the curtain, to chart. On some level I feel like each patient should understand how much time I spend doing work for them/their care.

If I go back out to the hall or nurses station to chart and a call light goes off... my boss who never worked as a floor nurse with computerized charting... asks why we aren't jumping up to answer the lights. If I am in the patient's room... then she sees I am with a patient. It's very different from when they kept a paper chart at the bedside or at a wall-a-roo. Loved wall-a-roos!