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Discussion

Charting

Hi, I have 7 shifts left in my preceptorship. When doing charts my nurse wants me to chart on clients that I haven't done anything with other than poked my head in once or twice on rounds. I do not feel comfortable with charting on them when she actually did something with them. Also last night one of the patients had not been charted on the previous night and she's like why didn't you chart on her and I'm like I dont know b/c I didn't know anything about her and she's like you told me you did. Ummmmmm NO I did not. I just don't know what to do. any suggestions

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Try talking to her before the issue arises. How about a two minute talk before you get report. Something like, "I think that you are asking me to chart on every pt so that you can be sure that I am charting correctly, and I am really impressed with the fact that you want my orientation to be thorough. However, I don't feel comfortable charting about something that you did or saw, can we find a compromise?"

Stick to your guns, charting what someone else should be charting is always an opening in a lawsuit, "Well Nurse Smith, didn't they teach you the basics of documentation in nursing school?" is sure to come out of an attorney's mouth and you would have no way to CYA!

  • Author

THanks

Try talking to her before the issue arises. How about a two minute talk before you get report. Something like, "I think that you are asking me to chart on every pt so that you can be sure that I am charting correctly, and I am really impressed with the fact that you want my orientation to be thorough. However, I don't feel comfortable charting about something that you did or saw, can we find a compromise?"

Stick to your guns, charting what someone else should be charting is always an opening in a lawsuit, "Well Nurse Smith, didn't they teach you the basics of documentation in nursing school?" is sure to come out of an attorney's mouth and you would have no way to CYA!

Just simply chart what ever you saw, pt sitting in bed, resp rate 18/min, unlabored, family at bedside, call bell in reach.... just for example, you will learn to be more observant and you will be able to tell many things about a patient just by looking at them for a few moments. Speaking from experience, charting is VERY important, you can lose your license for poor charting, dont ever let anyone tell you you chart too much, it is your license, not theirs!! Good luck, and just follow your intuition!!

LISA

  • Author

Thanks for the ideas.

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