Charting/Assessment Struggles

[studog12, BSN]

Hello All,

So, I have some burning questions about charting. Ever since nursing school, I have noticed that there seems to be some gray around this issue, despite always being told/taught that it is black and white (i.e., if you didn't see/assess/do it, then you don't chart it). For starters, I consider myself a very cautious/careful person and nurse, and that is from charting to assessments, to medication administration to giving report--the whole shebang. In short, I really care about doing things the right way and not cutting corners, even if that means taking more time, getting behind, and having to stay later to finish up after report is given. However, despite my passion for thoroughness, I still miss things. I am a new grad in a cardiac ICU, and the learning curve is steep with tons of things to remember to do at 7 a.m. when I begin my shift. Therefore, even with the checklist I made to prevent myself from forgetting something, it still seems like there is always something I miss, mainly in the head-to-toe assessment. I especially notice this AFTER I have done my head-to-toe when I am charting the complex assessment and there was more to assess than I realized. And certain things I miss can be routine, too. For example, I might forget to check for a brachial pulse on the arm in which the patient has a radial arterial line, or I might forget to make sure the patient has a stat lock for the Foley catheter, or forget to write down whether the patient's central line/IV dressings are "clean, dry, and intact" as previous nurses have charted before, or forget to write down if there is redness/ecchymosis on the left upper extremity or down on the right lower extremity. In other words, little details that are a routine part of the charting template that unless I go back into the room and check specifically, I can't really picture in my mind's eye whether or not those things are present/not present.

Consequently, I use the previous, more experienced nurse's charting as a REFERENCE (I would never copy!) just to make sure that I, as a novice, wouldn't miss anything significant but missed because, well, I guess I just missed it. I just worry that I don't remember details well enough, even though I am very detail oriented and even if I chart soon after my assessment. So, what I will sometimes do if I forget a few details is just agree with what was charted before, unless I absolutely disagree with it, which I will then chart my own perspective. And the reason I do this is because I have found that as I move through the complex assessment charting, there are several things I could go back in the room to check, but might end up making multiple trips and therefore seem like I am overthinking it, you know? I just struggle with this ambiguity. Charting is preached like it is black or white, but it just seems like there is a significant amount of gray. I mean, how can other nurses remember to assess all those details every time, especially when they are busy? It's not like there is a checklist manifesto that each nurse must universally abide by as they do their assessments. We each have our own liberty and autonomy to make choices about how thorough we want to be (even though we all should be as thorough as possible). And I want to be thorough and do my best to get it right every time (not trying to be a perfectionist--it's just important to me and for the sake of the patient)!

Anyway, I just wanted to see if you all had any advice about this. The risk of using someone else's charting as a reference as a new grad is if you chart on something he or she did and you do not really understand it and then it is discontinued or no longer applicable to the patient's care, you can end up "false charting." This happened to me and my preceptor noticed and it came up in my evaluations. And I understand that "false charting" is serious, but again I am not sure what to do given the urgency to be efficient and the impracticality of going back and forth to and from the room all the time to check those certain things I missed initially.

Thanks for reading the long post and for your answers. It means a lot that we can come here on this forum to ask questions and be honest.

Sincerely,

Studog

[Been there,done that, ASN, RN]

What did your preceptor tell you to do?

[NurseGirl525, ASN, RN]

If I miss something, I go back and assess it and chart it. I never go off of the previous nurse. Many times I am charting my initial assessment and realize I missed something. I get up, go into the room, and assess the items I missed.

Its my assessment.

[ohiobobcat]

When I was a new nurse, I found it helpful to look at other (more experienced) nurses to see how they charted. It helped me see the big picture and gave me a new/different way to look at some things. So I say yes, it's OK to look at the previous shift's notes on your patient. But don't chart those findings as your own. Use the previous shift's charting to help you organize yourself, and also to note any changes in your patient.

I wonder if you are too detail oriented and need to break your assessment down into categories and not individual tasks. Do you have a "brain sheet"? I used one on every patient when I worked in-patient. I would chart my assessment in short hand on this brain sheet. I had spaces for all the different body systems. I also had spaces for IV access, pertinent labs, dressings, etc. I did the same assessment in the same order on each patient for the most part. After a while you get into a groove on each patient and the assessment becomes second nature and you don't miss that central line dressing documentation (for example).

[HouTx, BSN, MSN, EdD]

Back in the day (crusty old bat here), as a neophyte ICU nurse, I learned to literally assess head-to-toe. We charted in narrative notes... very few checklists. By always using the same technique, it became much easier to recall any abnormality, including insertion sites for any tubes, lines & drains. Every initial assessment included flip and strip.... actually visualizing all parts of the body by moving aside the gown, removing TEDS, and physically examining the entire back. That was just the minimally acceptable standard.

IMO, it was much easier than clicking around on today's EHR -- where it's easier to lose focus because simply navigating through all those screens can be a distraction.

My advice? Develop your own systematic routine for assessment. Try not to succumb to distractions during your assessment because it's difficult to resume without forgetting something. Don't be afraid to use the "Not Applicable" option rather than waste time on irrelevant areas (e.g., pedal pulses on a bilat BKA). Talk to your patient as you assess & "discuss" what you're finding. Even if s/he is non-responsive, this will improve your recall.

[HelloWish, ADN, BSN]

If you can chart at the bedside, then you have your chart and assessment pulled up and will be less likely to miss something. I am coming off orientation as a new grad in one more shift and found this to be helpful. That being said, I do not always have time to do this.

[studog12, BSN]

Right. That's what I would prefer to do! But word around the unit is that when you do that people think you are trying to avoid being available to help out, so it's like I can't win! However, I still think I will experiment with this once I am on my own and see if I can find a routine where I can have time to do this.

[studog12, BSN]

Yeah, that's a good idea. I have recently begun to write down abnormalities that I see on my sheet of paper so I will KNOW what I assessed. I guess I can also write down anything I realize I miss during my initial head-to-toe when I am charting in the complex assessment, and once I am done go back and assess those things all at once to sort of cluster my care. But it's nice to have some validation that it is easy to forget something when one has so much to remember and take care of in a patient's room at the beginning of a shift.

[studog12, BSN]

@Been there, done that

Well, I didn't ask her, but let me explain a little bit. From the get-go she was very adamant about getting me to "move along," trying to push me to be efficient while being thorough simultaneously. That sounds good in theory, but the excess pressure she put on me was counterproductive and ended up making me worry more about my efficiency than my effectiveness (at least it seemed like I had to sacrifice one for the other). Plus, she had a difficult temperament and wasn't very inviting to me in terms of asking questions, so rather than just ask her about it I hesitated because of my intimidation. My mistake, I know, and I won't make that mistake again. The speed will come with time; I always need to focus on being safe first. Unfortunately because I didn't speak up she has concerns that I am not safe, which couldn't be further from the truth.