how do you chart?/question about shifts

[cmm4ever]

So supposedly my trainer taught me the wrong thing when it comes to charting. I was actually with a different girl today (who I like much better), but with other one this weekend I asked the girl a question about if baths should be charted under such an such time (8am). She said yeah and the nurse manager overheard us and corrected her. The girl who has been training me mostly, trained her also. So if it werent confusing already, I was originally told to;After vitals to chart them, pick up trays, then chart 8am adl's (including baths even if we didnt do them all then)., then later chart 12:00 adl's, I and O rounds, then 200 charting I's and O's Now the manager wants us to do the 8am vitals, then under adl columnar chart the adls/baths under the exact time, then also the 1200 adls, and 200 I's and O'S. How do you do it where you work? Anyways I was confused enough already. Just another extra step/thing to remember. Also, has anyone worked 7-3 fulltime and/or 7am-7pm fulltime? How was it? If I stick with this, I want to go fulltime eventually. I heard 7-3 fulltime can be very tiring, 7am-7pm sound like a long day also! Where I work 7am-3 fulltime I think is maybe 5 days a week, work everyother weekend and 7am-7pm is 3 days a week, work once every three weekends. I guess there are good and bad about both.

[Ytellu]

Honestly, asking all of us to tell you how we do charting at our respective hospitals, LTC, or other facilities will just confuse you more. What matters is what YOUR facility wants you to do and in what order.

Every shift is demanding. There is more to do during 7-3 because it is a two meal shift with bathing. 3-11 has it own challenges and there are a lot of cleaning and stocking duties at my Hospital on noc shift.

Concentrate on getting in a groove and learning about proper procedure before wanting to take on more hours or a different shift. Training on first shift is a good way cut your teeth as the saying goes.

[Hygiene Queen]

While charting is different everywhere, there are some aspects that hold true everywhere.

For example, you never chart anything that you did not do.

I think, from your post, that you were saying that you were told to chart baths even if you did not do them.

No.

Don't do that.

You may tell yourself, "Well, I'll just chart, while I'm here, that I gave the bath. Sure, I didn't do it yet, but I'll do it in a few minutes, so it's okay." BUT you are setting yourself up for trouble. You may get distracted or too busy with more pressing issues... and never get to give that bath as you fully intended.

Now you have put your name to a lie.

Please use your common sense and don't just do things because you were "told to". Think about whether what you are being told makes sense.

Being told to chart something you didn't do does not make sense... and it's falsified charting.

You can-- and should-- get fired for that.

Chart what you did, when you did it.

[cmm4ever]

While charting is different everywhere, there are some aspects that hold true everywhere.

For example, you never chart anything that you did not do.

I think, from your post, that you were saying that you were told to chart baths even if you did not do them.

No.

Don't do that.

You may tell yourself, "Well, I'll just chart, while I'm here, that I gave the bath. Sure, I didn't do it yet, but I'll do it in a few minutes, so it's okay." BUT you are setting yourself up for trouble. You may get distracted or too busy with more pressing issues... and never get to give that bath as you fully intended.

Now you have put your name to a lie.

Please use your common sense and don't just do things because you were "told to". Think about whether what you are being told makes sense.

Being told to chart something you didn't do does not make sense... and it's falsified charting.

You can-- and should-- get fired for that.

Chart what you did, when you did it.

I wastold to this by the girk that trained many others..I didnt know there was another way to chart a specific time. I did it the right way today.

[caliotter3]

An example of charting when you don't do something: A resident went home for the weekend and unfortunately passed away at home. The chart was gone over when closing it out and people were asked about things that should have, should not have been charted prior to the departure home. More than embarassing when the patient dies and you are caught in an act of 'erroneous' charting.

[fuzzywuzzy, CNA]

It doesn't matter how we all chart at our facilities because we don't work with you. That's like a Subway employee asking someone who works at Quizno's how they make their sandwiches. I don't understand why you always ask questions about how we do things specifically. You do realize that our answers are essentially useless, right? The members here can provide very good advice on universal topics like how to organize your day or deal with combative patients, but we can't possibly tell you how to look up information on your patients' assist levels-- that's something your preceptor has to show you (I could tell you that in my facility, you can look them up by their room# in the big blue book on the shelf behind the nursing station- does that help YOU? no). You say that your preceptor doesn't always answer your questions, but it seems like you're asking the wrong things and fixating on details that don't matter (like your orientation). And you've asked the same questions on here a zillion times and gotten good answers, so I have to wonder if you are really listening. You will be much more successful if you use common sense instead of asking for guidance on every little detail. Look at the big picture- don't be dangerous. Try not to drop people, forget about alarms, or give someone the wrong meal tray. The rest will fall into place as you go along, provided you don't switch shifts or find another job before you've even gotten a grip on this one.

[Ytellu]

EXACTLY fuzzywuzzy. EXACTLY!! :yeah::yeah: