Charting

Blu rose · Oct 16, 2011

I do my charting at the end of the shift to make sure I chart everything I did. Presently, we are required to write a progress note listing the care provided, any important information found (edema, bleeding etc.) or any procedures done (catheterization, wound dressing/packing, trach care etc.). Then, there are flowsheets where we put a check mark for the assistance given with the ADLs.(bed baths, shower, toileting, skin care etc.) While flowsheets and progress notes are charted on paper, vital signs are charted on computer. It depends on the clinical facility (last semster, I did computer charting only).

BrujahAngel · Oct 16, 2011

My advise is chart at every second you get!!! If your program is anything like mine, every second counts!! I like to take regular paper w/me to clinical and note times, proceedures, findings on that in shorthand, then transfer to actal paperwork to turn in later. Good luck!!

NCRNMDM, ASN, RN · Oct 18, 2011

I think it's a terrible idea to wait until the end of the shift and try to chart everything then. Our program forbids this practice, and we are required to chart each intervention as we go. If we do vital signs, turn a patient, give an IV med, and insert an NG tube, we leave the room and chart all of the interventions we have performed. I try to chart everything I did in the room as soon as I come out. I try to remind myself that each, "block" of patient care should include me going into the room, providing the care, exiting the room, and then charting the care provided. You know what they say, if it wasn't charted, it wasn't done. I agree with this philosophy. I think you should go into the room, provide care, wash your hands, leave the room, and chart what you did in the room you just left. Unless you are insanely busy, like if you are in ICU and with your patient all 12 hours because they are trying to code all shift, then you have no excuse not to chart as you go. Waiting until the end of the shift makes it more likely that you will forget to chart something, lose your vital signs, and generally make mistakes. As for what you should chart about, it depends on what you're doing. There are different things to chart for each procedure and intervention that you perform. You should already know what kinds of things to chart after inserting an IV, inserting a foley, inserting an NG tube, changing a dressing, emptying a drain, giving a medication, or doing any other intervention. Those are the types of things you learn during your first year, and use consistently. I don't think you have forgotten those things over your summer break, not if you learned them and charted like you should have during your first year.

turnforthenurse, MSN, NP · Oct 18, 2011

I think it's a terrible idea to wait until the end of the shift and try to chart everything then. Our program forbids this practice, and we are required to chart each intervention as we go. If we do vital signs, turn a patient, give an IV med, and insert an NG tube, we leave the room and chart all of the interventions we have performed. I try to chart everything I did in the room as soon as I come out. I try to remind myself that each, "block" of patient care should include me going into the room, providing the care, exiting the room, and then charting the care provided. You know what they say, if it wasn't charted, it wasn't done. I agree with this philosophy. I think you should go into the room, provide care, wash your hands, leave the room, and chart what you did in the room you just left. Unless you are insanely busy, like if you are in ICU and with your patient all 12 hours because they are trying to code all shift, then you have no excuse not to chart as you go. Waiting until the end of the shift makes it more likely that you will forget to chart something, lose your vital signs, and generally make mistakes. As for what you should chart about, it depends on what you're doing. There are different things to chart for each procedure and intervention that you perform. You should already know what kinds of things to chart after inserting an IV, inserting a foley, inserting an NG tube, changing a dressing, emptying a drain, giving a medication, or doing any other intervention. Those are the types of things you learn during your first year, and use consistently. I don't think you have forgotten those things over your summer break, not if you learned them and charted like you should have during your first year.

This, but in the real world, sometimes you will have to wait HOURS after doing something or closer to the end of your shift. If that's the case, I write down little notes and the time it happened - for example, "@2245 voided 300cc's" or "@2100 Dr. so-and-so in to see patient. awaiting orders" etc. I try to chart at every opportunity I get, even if it is something simple such as "patient resting comfortably in bed; no needs at this time. call light w/in reach" - but we have other areas in our charting system indicating that we are rounding on our patients. Some nurses' charting is horrendous; it's like they do not chart anything during the whole shift except for assessments. I feel like I chart A LOT compared to some of my coworkers, but I would rather chart too much and cover myself instead of charting too little and possibly be questioned by it later. And remember if you didn't chart it, it wasn't done!

Blu rose · Oct 19, 2011

I think it's a terrible idea to wait until the end of the shift and try to chart everything then. Our program forbids this practice, and we are required to chart each intervention as we go. If we do vital signs, turn a patient, give an IV med, and insert an NG tube, we leave the room and chart all of the interventions we have performed. I try to chart everything I did in the room as soon as I come out. I try to remind myself that each, "block" of patient care should include me going into the room, providing the care, exiting the room, and then charting the care provided. You know what they say, if it wasn't charted, it wasn't done. I agree with this philosophy. I think you should go into the room, provide care, wash your hands, leave the room, and chart what you did in the room you just left. Unless you are insanely busy, like if you are in ICU and with your patient all 12 hours because they are trying to code all shift, then you have no excuse not to chart as you go. Waiting until the end of the shift makes it more likely that you will forget to chart something, lose your vital signs, and generally make mistakes. As for what you should chart about, it depends on what you're doing. There are different things to chart for each procedure and intervention that you perform. You should already know what kinds of things to chart after inserting an IV, inserting a foley, inserting an NG tube, changing a dressing, emptying a drain, giving a medication, or doing any other intervention. Those are the types of things you learn during your first year, and use consistently. I don't think you have forgotten those things over your summer break, not if you learned them and charted like you should have during your first year.

Well, charting as you do things may be a good idea but, real life nursing can be really busy and you might not get the chance to chart after providing care to each client (that's what my clinical instructor said). So, I always keep a small notebook with me (that can fit the pocket of my scrub) and keep writing the important information, vital signs, the assessmentsand and the time in it.Then, later on I transfer it to the client's chart which actually decreases the risk of making a mistake because it's like a double check.

loriangel14, RN · Oct 19, 2011

In real life charting as soon as you have done something is pretty much impossible.Sometimes I don't get a chance to sit down until hours after I have done something.