Charting etc

[nurse-ct]

I am new out of school and new to my job. I am terribly bad at charting. I use to be better when in school and on rotations but once you get into the real work environment, it is not so.

On rotations we are taught to assess FIRST and document. In the real job, because we have so many patients, we do not have the time and it is as if it is not required. Also, once I wrote something that I saw and people were mad at me.

It makes me afraid to chart because then your job feels threatened.

What if the pt has no GTube, no ulcers and just on regular meds. What is there to chart at the end of the day?

[calivianya, BSN, RN]

My first thought - who's reading your charting and getting on you about it? Your charting is YOUR charting. It is what you saw. If someone else has a problem with it, it's that person's problem. Unless it's this person's responsibility to audit your charting, it is none of that person's business what you chart.

You really need to assess your patients before you chart anything. I understand we get busy - sometimes I don't have time to do everything I'm supposed to do, either. But, if you haven't assessed the patient yet at all, how do you know what you're charting is anywhere close to what is actually going on with the patient? Don't forget that the medical record is a legal document. You can be called into court on things you charted, so you should at least make sure that something is accurate before you chart it.

I don't know what your requirements are in your workplace. Here's an example of what I chart:

- Pupils, LOC, GCS score, movement in all four extremities (follows commands or response to pain/strength of movement), occasionally bother to ask if a stone floats on water, etc. (delirium)

- Heart rate, rhythm, sounds (abnormal or just S1, S2), JVD, edema (where, how bad), at least four pulses, capillary refill

- Lung sounds, symmetry of chest expansion, what sort of O2 device, what settings

- Bowel sounds, abdomen shape/tightness, what kind of diet, any tubes, any residuals, when the last bowel movement was

- Urine color, clarity, size/type of catheter, amount of urine

- Skin color, temp, turgor; wounds - what type? What does the base look like? How big? What type of dressing? Is the dressing clean or soiled?

- Is the patient weak? Where? Do they use assistive devices? How much assistance do they require with tasks? Are there any amputations?

- What sort of access do they have? Does their IV show signs of infiltration? Phlebitis? Is it infusing or is it saline locked? What's running?

- Psych status - are they calm, anxious, etc. - is the family member in the room? How is the family member acting?

- What is their VTE prophylaxis device? Do they have VTE prevention orders?

- How many side rails are up on the bed?

Check out your facility's policies and procedures - it's entirely possible they will tell you exactly what they expect you to have charted on your patients, and how often you need to be charting those things. Necessary charting varies a lot from location to location.