CHARTS CHARTS...

[Lilia777]

Hello everyone! I hope everyone is doing well,?my question is quick: during all my clinical placements it seems that every senior nurse has a completely different take on charting.... this left me quite paranoid and worrisome, many say "chart by exception", many say "chart everything in detail". I got very good evaluations throughout my RPN program but the charting was my only issue. Please help me get to some type of conclusion because I am about to enter a bridging program to BScN and I must iron all my wrinkles now especially because as we all know, charts are legal documents which can have major consequences in the future. If anyone has a good resource or something of the kind, I will forever love you. Thank you all, and I look forward to all responses- L

[Lilia777]

Anyone? Charts? Thoughts? :/

[Fiona59]

I have lots of thoughts and you probably won't like them.

Find out what the facility policy on charting is. I chart by exception and document dressings and their conditions. Any strange or "off" comments by the patient or their family is documented.

In two decades, I have never been called into a Court over my charting. I have heard that the charting I did on one patient and his family was used to show that there were unreasonable expectations from the day the patient entered our facility for care.

What I do have a problem with is how most RPNs in Ontario seem to want to do the bridge before even working as a PN. In my province over 1300 hours of work as an LPN are required to enter a bridging programme. During this time we hone our skills, and learn how our facilities expect us as working nurses to document care.

[Lilia777]

Thank you Fiona59, I definitely have looked into the policies for charting, the reason I was asking for further guidance/information, is the fact that in all of my clinicals, (even within the same facility or unit believe it or not), we heard different opinions on the matter from nurses who were there for quite some time and I do try to listen to experienced nurses as much as I can. My profs in all courses really emphasized the importance of charts, we were taught that charting is an extremely important legal document thus everything that you document can save you or break you. That's all, I just want to give it all my best. I do have a logical, systematic way that 2 of my preceptors showed me, my question was more about how much into detail would be preferable and time efficient. I appreciate your thoughts though!