Charting within a team nursing environment

[epg_pei]

Hi folks,

Two weeks to go until I complete my preceptorship. I have gained so much in practical knowledge in this preceptorship. I think I should have had much of it down before now, but so long as I get it....Documentation remains a major problem though. Throughout school I did clinicals in facilities where primary nursing was the standard practice. I thought you chart what you saw, what you assessed, what interventions you took, personally. I'm now on a unit where team nursing is used, and I am having a major problem with the charting practice. On this unit, you work with a team partner, either as leader or worker. Leader usually does meds, worker does cares, with cooperation to ensure everything is completed. But at the end of the shift, the unit charts are somewhat arbitrarily divided, at least that's what it feels like to me. And I feel like I am having to make chart entries on patients I have had little interaction with. I often don't feel I really know what's going on with the patients, other than what I can gather from their medications and brief discussions while administering meds. And the chart entries reflect this ie charting entries forcused on "comfort" or such.

Anyway, I guess what I am wondering is have any of you been in a similar situation. Have you felt disconnected like this? Do you have any strategies to improve your level of knowlege with the patients, that are practical given the typical patient load. Thanks for all responses!

[pickledpepperRN]

You can't chart what you didn't see. I think the "leader" needs to assess all the patients while "worker" performs tasks and documents them. Of course a "worker" may notice something or the patient may tell him or her something importans and it needs to be charted and reported to the "leader".

Check the written policies and procedures.

I think either communications needs to improve or the unit is understaffed.

Dividing tasks to ensure everything gets done is good, but someone has to be responsible for the nursing care.

[Daytonite, BSN, RN]

back in the early 70s when i was in training we were taught under the team nursing and functional nursing models. with functional nursing every team member is often given one major task to accomplish such as pass medications, attend to ivs, carry out treatments, make rounds with the doctors. when you are working in a team and there is a good chance you are not going to have a lot of direct contact with some of the patients you have to maintain lines of communication with your team members. what i would do is in passing (often in the hallway, or when i met someone at the central supply cart or in the pantry) i asked about the patients and got information. you have to know the patients so you can ask the right questions of the other nursing staff. you can't expect them to automatically come to you with a report. that's a lesson i learned the hard way. that is just plain suicide. you will have to be the proactive one to seek them out to find out the information. if they give you a piece of knowledge that might set up set red flags or questions in your mind then you just make the time to go in to that particular patient and check out the situation. this is where is becomes important to learn to determine very quickly what is important to focus on, what you can let fall to the wayside, and prioritize your actions. you just always keep a running list in your mind of the patients you are responsible for and what you need to absolutely know about them as your shift proceeds. in actuality you should only be focusing your narrative charting on things that pertain to major problems the patient is being treated for or that have been addressed with the patient that shift. the "normal" stuff doesn't need mentioning in narrative notes, especially if you have a check off system of charting or unless the patient has gone from a illness state to a healed state (as in congested lungs to clear lung fields).