Charting and Codes

VenaKavaRN · Feb 6, 2009

What are you being told to chart? If it's vital signs or intake and ouptut, objective stuff like that, then I'd see no problem with a nursing student doing it. It's if you're being told to do nurse's notes I'd be a little concerned. If you're being encouraged to do the nurse's notes, make sure the primary nurse reads over it to make sure you got everything she wants on there.

Unless you're the only one in there and the patient is for sure not breathing or has a pulse, get the patient's primary nurse first before you call a code. Since it's a telemetry floor, I'd reckon there's 3-4 people watching that patient's heart rhythm at all times, and they'd know when something was going wrong in that department. If you think the patient's doing downhill fast, stay with them until the nurse comes, and if they go into respiratory arrest, then call the code.

The only code I've seen was when a patient went into cardiac arrest on the toilet :uhoh3: I just stood waay back when the code was called, since people were running down the hall with a crash cart. Just stand close by outside the door, ready to get anything they say they need - towels, suction, epi, whatever.

lemonaidangel · Feb 6, 2009

I am in my last semester and we have always had to do charting on our patients. The first semester we mostly just charted vital signs and basic assessments, but as we worked our way up we did more and more with the charts, including nursing notes. Obviously the RNs like to do their own charting just to cover all their bases, but for the most part we are pretty proficient at working our way around the computer systems and paper charts by now. I think it is a great learning opportuntity. After all, when we graduate we are going to be charting on everything. We might as well get used to doing it the official way now so that we aren't so clueless when we work on our own.

As far as codes go, I would think the best thing would be to look up hospital policy. Certainly if the patient isn't breathing or has no pulse you should call a code immediately and start CPR, but if you aren't sure what is going on with a patient you should grab the closest nurse and let him/her assess the situation. Like the above poster said, on a telemetry unit, there is always someone at the nurses station monitoring the rhythms.

Daytonite, BSN, RN · Feb 6, 2009

i go to my first clinical today and am told that we will be charting on the pts chart. does that sound right? is that what everybody else does?

when i was in nursing school 30+ years ago we charted in the patient's charts after our instructors approved our charting first. over the years as a working nurse in the many different hospitals i worked, the student nurses charted in the patients charts. do you want to know why? because you are doing things for these patients. you need to document the care that you are giving to them in your own handwriting and in your own words. you don't pass the buck. if you do something you take responsibility for it.

also, when do you call a code?

you call a code blue when you are with a patient who stops breathing or you find a patient who is not breathing or has no pulse.

has anybody experienced a code? what did you do, what do you wish you did, and what happened?

i worked on a stepdown unit for many years and we had a fair share of code blues. i was also an acute hospital supervisor and had to attend all code blues so i saw plenty of them. every hospital has a policy and procedure that the nursing staff is to follow when a code blue is called. during your orientation as a new employee the code blue procedure will be explained to you. many hospitals today have a code blue button in the rooms that you merely need to push to set things in motion. in most cases, when we had a patient, or found a patient not breathing or without a pulse we picked up the phone and notified the hospital operator that we had a patient that was a code blue and gave the location. i note the time. the operator had her duties to notify a series of people and make overhead announcements. meanwhile, i would be getting the patient flat in the bed, removing pillows and getting ready to start cpr. if i am alone, single rescuer cpr; if i had called for someone to come help, 2-rescuer cpr. someone from the unit should be bringing the crash cart to the room. respiratory therapy, the er doctor, nurses from the er and/or icu, the supervisor and security should be showing up momentarily. rt, the doc and the er and icu nurses take over running the code. i stand back and document what is going on and the times on the code blue sheet in the crash cart. this sheet becomes part of the patient's chart and is the official documentation of what has gone on during the code. i, at the direction of the doctor, will notify the patient's physician and let him know that his patient is being coded. some patients will survive and some won't. the patients who survive get transferred to the icu. you will find yourself questioning your actions at your first codes. everyone does. coulda/shoulda things will go through your head. you will seek the answers by asking others who were on the code team so you can do better the next time.

the biggest concern i saw nurses having were "did i wait too long before calling the code?" making that decision that the patient wasn't breathing is probably

the

hardest one you'll ever make. nurses beat themselves up later over all the things they did to try to figure out if someone was breathing or not. you can't always tell by skin color. they worried that if the patient died they waited too long and if they had called the code earlier the patient could have lived. from the time someone stops breathing until the brain starts experiencing anoxia is how many minutes? in all practicality, if you can't establish that someone is breathing and their color doesn't look quite right to you, just trust your instinct and call a code. if you are wrong you can put up with the embarrassment and figure out your mistake later.