charting

[grace08]

Is it common practice to back chart? And is it appropriate to do this? By this, I mean if you forget to chart something on your shift and then you remember and chart it the next day or at a later date.

[RNtoACGNP]

It is usually possible in electronic charting, but I would try your best to avoid it. Do your charting AS things happen, as hard as that is it will save you in the long run. I found a new way of remembering things in the last year that helps tremendously. We have a separate "report" sheet for each patient that we receive during report, it has all of the information you could possibly want, but it can be hard to scribble notes and actually remember to look because there's so much other info. So what I do is I write recent lab results and my assessment findings on each individual report sheet, I staple them together with a half sheet of blank computer paper as the top sheet. On that half sheet I write room numbers and names, and leave an adequate amount of space to write notes throughout the day. I write any tests, pertinent vitals/critical labs, weird meds that are scheduled at odd times, and ANYthing that comes up during my shift that's a change from how I got the patient at 0700. It helps soooo much with charting and giving a good report to the incoming shift. Another thing that helps is I write in different colors like bright red, blue, green.. To help things stand out to me.

[HouTx, BSN, MSN, EdD]

Check your employer's policy on this to see how they want to handle 'late' entries. No matter how organized you are, there are times when something will just fall through the cracks. As long as you follow the policy, you should be fine.