Charting questions

[fjluce]

I recently transferred from the floor to an ICU. I am by no means a seasoned nurse, but I have some experience and with this particular patient population. I will admit I am struggling with the orientation period. Not that I don't feel like I don't need to learn, but rather the fact of using my time in a way that works for me as opposed to my preceptor. She's very thorough and I do appreciate that especially when looking for the learning experience I am hoping to get out off orientation so I come off of orientation as a competent ICU nurse. While charting (using Epic)I try not to waste time on things such as if charting a respiratory assessment charting WDL and not charting lung sounds are clear under each field. If all lung sounds are coorifice I'll chart ex and the side of the body I listened to and then I'll mark coorifice. When not all fields are coorifice I will chart the ones that were as coorifice and the others as clear or whatever sounds were heard. To my preceptor this is unacceptable. She wants every line in Epic filled out. For example, my patient was sedated, I was unable to assess orientation, I charted it as such and put a comment UTA, pt sedated. While providing a sedation vacation, my patient did not open her eyes, but while providing cares, I did say "you're at the hospital" under reorientation measures I charted reorientation provided. While reviewing my charting she said I needed to chart clock in view, calendar in view,and whatever other options there are. I tried explaining she didn't open her eyes as the reasoning behind me not charting these things, and even if she did, she wouldn't have been able to see the clock. I am willing to comply because I'm not on orientation for forever and I get how in theory this should work. Anywho, in others opinions/experience is the double charting necessary and is it wrong of me not to chart something I did not provide?

[Sour Lemon]

I am willing to comply because I'm not on orientation for forever and I get how in theory this should work. Anywho, in others opinions/experience is the double charting necessary and is it wrong of me not to chart something I did not provide?

It is "necessary", because like you said, you're on orientation and it is your preceptor's wish. After that, refer to your employer's policies for guidance. I tend to chart the way you do, but there are some "useless" things that my employer does require to be filled in.

[Crush]

Never chart anything you did not do. Perhaps asking your preceptor for clarification? I Like what Sour lemon wrote, however, my personal thing is if they want you to repeat, double chart and that is the norm on that floor then when in Rome......................

[SC_RNDude]

Grin and bear it while being oriented. Once your on your own, you can do what you think is right.

[mrsboots87]

Side note, clock in view and such does not mean that the patient is looking at the clock. It merely means that the clock is in the line of sight of the patient and not behind their head. r lets whoever reads that charting for whatever reason that you had re orientation measures in place for when/if the patients awakens.