Published Jun 29, 2005
Okay, I just started my first job as a Clinical Assistant while I'm in school for nursing (hopefully I'll start my clinical program next fall). My preceptor is telling me that when I chart vitals and the procedures I do, I should put in the time done at the time I put it in the chart. But when it's busy, sometimes we grab vitals on 6 or 7 pts in a row before sitting down to chart. Since I'm still learning, it takes me a while to get each set of vitals, and by the time I'm done with 5 pts, it's been almost a half hour since I did the first pt. Should I put them all in at the same time, or write down what time I took them along with the vitals so I can put that time in on the chart?? My preceptor puts them in as the time she's charting, so for example she has 7 pts charted that she did vitals at 1900, when she really did the first pt at 1830, second at 1840, etc. I don't want to get in trouble for charting errors, and if I ask the nurses, they'll tell me to ask my preceptor, or if I explain, I'm afraid I'll get her in trouble and the next 5 weeks of my orientation will be a living h*ll. What should I do? I would think it would matter to document what time the vitals were actually taken if it's that much of a time difference??
If I were the one concerned about this I would check and see what the hospital policy is. You could ask a supervisor without calling a specific person out. Maybe just say, I've noticed everyone one does it a little different, what is the right way so I'll know for me. Then you will know exactly what you are supposed to be doing and nevermind what anyone else says. That sounds mean but I didn't mean it that way. I just meant in the back of your mind you could be thinking that you know how it is supposed to be done.
You could make a little note on a piece of paper when you walk into each person's room as to what time it is. Then when you go back and chart put that time as the vitals. I don't see how you could go wrong with doing that. If you start taking vitals at 1830 and chart at 1900 and put 1900 as the time you took the vitals that is inaccurate.
that's what I thought would be the most accurate way of charting vitals. Occasionally when my preceptor charts vitals, the time she puts in from her watch is a few minutes ahead of the clock on the computer, so the computer charts that at 1900 such and such a person entered that vitals were taken on room 28 at 1904. THat looks bad, as if she's pre-charting, and I don't want that to happen to me. I think I will start charting the time I actually took the vitals, keeping record on my pad of paper what time I took the vitals, continue to the next pt, etc. and when I do charting I will put in the time I wrote on my paper. I'm also going to ask my nurse manager if that's how she wants me doing it. Thanks for all your advice!
How common is it to have the EXACT time vital signs are taken? We have computer documentation and the secretary puts the vital signs in at the same time - not the exact time the clinical takes them.
I'm a labor and delivery nurse. A couple weeks ago I had a patient come in complete and delivery within 2 minutes of getting in the labor room. The time that she delivered per our fetal monitor, was before the time her hospital ID bracelet said she was admitted. Her admission time was something like 2104 and her delivery time was 2102. Very confusing!
I know that generally it is not very common on say a Med/Surg floor to chart the vitals for the exact time you take them. I guess what I was thinking was that if a patient went bad or something and you were asked for last vitals they could possibly be like 30 minutes older than stated. For example, at 1920 if the doc asked about vitals and you said blah blah blah at 1900 ... that makes it sound as if they are only 20 minutes old, when in fact they could be almost an hour old if they were actually taken at 1830. I suppose this kind of situation would be more important in a critical care setting.
Most charting times, like meds, have a "window". At one hospital I worked at the 0800am vitals were done by the night shift b/c days was too busy however they were the morning vitals, started somewhere around 0600 am. Charted in the computerized 0800am slot. In an ICU time is far more critical than on a non-icu floor. That being said a non-icu floor can have a critical patient. Sometimes it comes down to a per patient thing. However, check with policy.
I would check hospital policy, but if/when I do vitals I chart the time they were gotten for....example, we have a graphic record for vitals....they are required at 0800 so the vitals are charted under 0800 block. If your facility doesn't use graphic records, you can most likely get away with estimating the time you took the vitals....it isn't terribly important that vitals be charted at the exact time they were taken.....as long as you put them down as close as possible......and some facilities allow a 30 minute before/after time period to count for the time it was suppose to take place.....example 0800 vital signs taken at 0745 would still count as 0800.
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