I am really liking the ER so far and I find it very challenging both mentally and physically. I'm trying to get a rhythm and flow and am trying to understand the thinking process and work-flow of an efficient ER nurse. My preceptor is a good example. They look and see what needs to be done and starts with that, what meds need to be given, what procedure needs to be done to keep the ER flow going. A quick scan of patients, make sure they are stable, then move on to the tasks and during that process, get vitals, necessary info, assessments.
Somewhere in that flow of proper prioritization (patient needs ABCs and down the line) to getting patients in and out of the ER the charting of vitals, rounding, other documentation is supposed to taking place. I have found that it is very hard to catch up on charting, but the charting needs to be done. When do I do it then? There's got to be a method.
There is only 1 time in the ED- NOW. Do it, chart it, because there is no later. You can never remember everything and if you fall behind you will inevitably leave something out. Unless someone is literally dying, take the time to chart before the next task. Good luck.
Vouch. I've had other staff discharge my pts when I was busy. Having that charting done makes it easier for everyone.
I try very hard to get it done before moving on to the next patient. I will only not chart and see a new patient if their heart rate is 150 or they are hypotensive or coding or something. Charting doesn't really take that long. I am a bit of a "bare bones" charter as well and I am working on being more detailed but still being as efficient. If I know I have a busy patient I will stay in the room and chart everything so I am not pulled in 5 directions the second I leave the room and get sidetracked. The only time I don't chart right away is when I have a critical patient. I chart the assessment and vital signs as soon as the patient is stabilized somewhat and then get them settled and then get started on that long note for ICU.
ASAP; most of the rooms have computers or areas have WOWs in them.
I will take vitals and have a roll of tape to document them and tape them on my arm or place them on my scrubs if I do quick rounds and settle pts once the initial assessment and interventions are done; then I will chart elsewhere and do a quick note.
I use Cerner, and my version does not allow for nursing notes; however there are so many options that I take advantage of where my documentation tells a story, or so the chart auditors tell me.
I use Cerner's FirstNet and it did take a little getting used to. I "touch" every system, but I focus on the problem area. As one poster above stated, the ER knows only ONE time... NOW!!! Fortunately for me, I do retain patient assessment info in my head for hours if necessary, but I'll dump it from memory once I have a chance to do some actual charting. Once you get used to the flow of FirstNet, it's not that difficult to work with and I can do my initial charting in about 2 minutes as long as I'm not interrupted.
I chart my "nursing note" in a section labeled something like Clinical Note ED. That section is also good for charting events that happen, such as when a patient goes to CT or gets a meal or someone visits...
I see a lot of WHEN do you chart. But WHAT you chart is just as much of a time suck as when. If you miss a bathroom break, or leisurely walk, or pt's family is at bedside, not an issue with most of our peeps.....unless it is. Chart what is important to their visit, and any other serious health concerns while in your care.
If they walk the bathroom, and are there for a hand lac, I don't care and I don't chart it, unless something else comes up (like he cut his hand cause his etoh was 570) well then if you are walking him to assess his gait and coordination hours later to discharge him, it's important to chart that he walked to the john with a steady gait, without difficulty, tolerated it well, whatever you need to say.
Unless it's a critical situation, I basically refuse to be interrupted when I'm charting. There is a huge hit in efficiency and accuracy by not charting in near-real time.
It's not enough for you to set your priorities, you must then execute them. Others will generally not respect your decision to focus on one thing until it's completed unless you stand your ground with a "just a moment" or some similar phrase.
The true seconds-to-minutes emergencies are relatively rare.
Also, if your EMR permits it, make liberal use of template phrase shortcuts.
Recognize, also, the risk that you face by delaying your charting: If something goes bad and you haven't charted anything yet then you have nothing to back you up because you'll be charting *after* the event which can put the veracity of the charting in question.
Even a simple note like, "pt visualized, resting quietly, respirations even and unlabored, on monitor, IVF infusing without evidence of complication, call light in reach, no signs of acute distress" can be whipped out in less than 30 seconds but provides coverage.
BTW, don't be fooled by the ESI level... 3's can be much sicker than 2's.
Unless it's a critical situation, I basically refuse to be interrupted when I'm charting. There is a huge hit in efficiency and accuracy by not charting in near-real time.
Yes. We have to think of charting as an essential component of our care, not something that can be set aside for later. Even at your busiest, you would be sure to clean up all the supplies from your IV and make sure your patient was comfortably settled before you moved on to the next one. Charting is the same.
Of course in real life we sometimes get backed up, and I've had a few situations where I had to back chart major parts of my shift, but at least 90% of the time, I get it done in real-ish time. My prime motivation is getting out of work on time, but I also know for sure that real-time charting is much more accurate than piecing it together from memory and chicken scratch on a paper towel.
BTW, don't be fooled by the ESI level... 3's can be much sicker than 2's.
This is SO TRUE.
ESI is only a tool... and as such, it isn't perfect. You have to constantly reevaluate your patients because their acuity level can change quickly and dramatically and if you don't pick up on that, you can be quite surprised...
I am really liking the ER so far and I find it very challenging both mentally and physically. I'm trying to get a rhythm and flow and am trying to understand the thinking process and work-flow of an efficient ER nurse. My preceptor is a good example. They look and see what needs to be done and starts with that, what meds need to be given, what procedure needs to be done to keep the ER flow going. A quick scan of patients, make sure they are stable, then move on to the tasks and during that process, get vitals, necessary info, assessments.
Somewhere in that flow of proper prioritization (patient needs ABCs and down the line) to getting patients in and out of the ER the charting of vitals, rounding, other documentation is supposed to taking place. I have found that it is very hard to catch up on charting, but the charting needs to be done. When do I do it then? There's got to be a method.
I work in ICU so it's not like the ER in some respects, but we also have critical care charting like you guys have. It's like you said about your preceptors: Do what needs to be done first, the chart it later.
What I do is similar, but I'll have a little notepad (not those super small, but cute, memo pads, but a medium-ish sized one that I can fit in my pocket) that I write down important stuff in. For example, if you give a PRN or note something new/weird in the pt assessment, write down the time and what happened (or the response to a therapy if need be). Do it legibly though, because it may make sense to you in the moment, but you do have to be able to chart it accurately and what makes sense when you're in a hurry won't always make sense when you have a minute to chart.
Also, and I've felt this a lot as a travel nurse, getting used to the charting system as fast as humanly possible helps a great deal so that you're not looking through each and EVERY option when you're charting. Saves a lot of time.
The mobile computers have also helped with this a great deal because you can chart things while you're in the room with the patient. It eventually comes down to experience, practice, and how well you know your EMAR, which will come with time. When you're new it feels like you're the slowest being on the planet (I feel that feeling every 13 weeks if I'm using a different system), but after a couple weeks I'm charting as fast as everyone else.
Also, while it doesn't have anything to do with charting directly, grouping your care and getting the layout of the unit as well as knowing which supplies are where will save you time. This, in turn, will let you have more time to chart. Also, if you can delegate things to other people, do it. That will also save you time and let you focus on other things.
I try to do my initial assessment/meds asap because then, if something else happens, I'm as caught up as humanly possible. It is a bit different in the ER because of what you guys do (I only float there if I absolutely have to cause it's not my jam:p, but I get the concern), but the basic concepts are the same. Anything you can do to save yourself time will either give you more time to do other things like chart, or at the very least, make you feel accomplished and that you're "getting it":sarcastic:
Good luck...sounds like you're doing swell xo
P.S. Also, most systems (even the exceedingly stupid Paragon system) have a feature that allows you to stop charting, if you've already started, and pick up where you left off when you come back to it. That helps a lot because most of the time we can't chart everything at one time because of interruptions.
pockunit, ADN, RN
614 Posts
Vouch. I've had other staff discharge my pts when I was busy. Having that charting done makes it easier for everyone.