Clinical Site Rules for Your School?

[lilarox]

I am wondering if your school is anything like mine. Different hospitals have different rules for the nursing students, and since I have been in nursing school the rules have changed so much, to the point that I feel like I am not getting sufficient experience, or equal experience. So, please share with me your experience at clinicals related to rules of the clinical site.

We are NOT allowed to document head-to-toe assessments on the patients electronic chart, (and they do not keep paper charting), we are NOT allowed to document medication administration under our name, it has to be charted under a teachers name.

Basically the only things we are ALLOWED to chart are the hourly checks (normally the CNA does that), and things like baths, sheet changes, meal consumption.

This change just occurred during my second semester, and of course the reason is a secret. So what are you allowed to chart at your clinical site?

[amanda081106]

I think it depends on several different factors, the facility and the clinical instructor being the biggest two. Last semester we didn't do any of the actual charting. The facility I was at had specific notebooks for students, and we simply wrote in the time that we completed the task, such as ADLs, I&O, etc.

This semester I am at a different facility with a different instructor and I have gotten to chart. I don't have a username/password yet, so I had to chart under the instructor's name, but she is working on getting that.

However, I don't really feel that charting is something I need to do right now to feel good about my experiences. It's like my clinical instructor told us, "Don't get caught up in trying to learn the computer system and the 'correct' way to chart. There is no absolute correct way, and these computer systems change frequently." She also went on to tell us to focus on the patient and our learning experiences outside charting.

[BeenThereDoneThat74, MSN, RN]

Amanda raised a very good point: clinical should not be about mastering the computer system. Where I teach, our students do not document either; i have them write paper notes (or they email them to me, basically via phone while in clinical sometimes). We also have an educational EHR that our school invested in. Some of the clinical groups use it. My groups have stated it really doesn't make a difference in enhancing their clinical experience. The reasons are not a secret; it is a tremendous undertaking to allow non-licensed, non-employees access to the computer. As an instructor, it is equally frustrating for us.

My students have access under my username. They type in nothing: I "sign" their meds, and make them swear to God they will not enter any data. They look up the meds, orders, history, and other pertinent data. Then next semester, they need to learn a whole new EHR. They all adapt pretty well.

[jesskidding, LPN]

We do not document anything. We do our own head to toe assessment to turn into our clinical instructor. If we do get vitals, give baths, etc. We report this to the CNA who documents our information. Any nursing related duties are given to the pts RN who documents them such as dressing changes, etc.

When we give meds it is automatically documented in the MAR under our clinical instructors name. When we get meds from the Omnicell it is through our clinical instructors log-in and password. Also when getting supplies, etc from the Pyxis we use the same clinical intructors log-in.

We are given "charting by exception" to use as we wish, but we do not have to turn them in.

I agree that as student nurses we shouldn't be worried about learning to chart in our clinical setting. Most facilities use different systems such as Paragon, MediTech, etc. Who knows what we will be using when we start working as RN's. I don't see any need for us to chart anything.

We also turn in our own "narrative assessment" to our clinical instructor which is attached to our care plan.

[OB-nurse2013, BSN, RN]

I just wanted to say the poll wouldnt let me vote for mor ethen one thing. My school and clinical sights so far, I'm in my third semester, allow you to chart your assessment, med's and anything else you do. Our clinical instructor co-signs everything at the end of our shift but thats it and it goes under our name. I'm suprised they won't let you..

[MN-Nurse, ASN, RN]

Sound like my peds clinical. My medsurg clinicals were not like this though. Quite the opposite.

[abiklags]

fundamentals and basic med surge we charted v/s, meds, blood glucose etc. psych we did nothing. OB rotation we charted nothing but did narrative nursing notes for practice. Peds we charted v/s, meds, i&o's neuro checks, GCS in the computer. we also wrote FDAR notes which were put in the paper charts. advanced med surge has dif rules for each of the 3 floors we visit. like some floors allow fall risk but not skin integrity, but others allow the exact opposite. community has a whole dif set of paper work we fill out and hand to the coordinator for the rotation.

re HtoT's, we do them on the floor but we don't chart them.

we chart under our instructors sign-in except in peds we had to add a note saying 'admin by____, supervised by _____ RN

[juliaann]

We're required to chart anything that we do. Daily assessments/PCA assessments/restraint assessments have to be co-signed (electronically) by the patient's nurse. Daily care, meds, IVF, skin score, food, and pretty much anything else we can chart under our name with no co-sign. Our instructors have access to everything we chart so they make sure nothing looks strange, but we're supposed to chart everything for our patient/s. I'm glad, too, because that was we get more of a feel for what it's really like to be a nurse for our assignment.

[jesskidding, LPN]

I think once we are further along in our program (ADN) we will have more freedom to chart. Especially in our preceptorships. It really depends on the facility you are at. The hospital we are in clinical does not want student nurses charting. I suppose for legal reasons.

[NCRNMDM, ASN, RN]

At the facility I am currently at we do everything, and we document all of it. We give meds, do head to toe assessments, insert IVs, NGs, and foleys, remove lines, NGs, foleys, take vitals, turn and position patients, ambulate patients, empty drains, etc. We chart our head to toe, all of our medication administration, all of our vital signs, our I&O, turning and position, incentive spirometer use, and any procedures that we do. We chart all of this in the computer under our names. Our names do, however, have a student designation behind them.

[mindlor]

I would not worry too much about charting. Wherever you end up working is going to reteach you their way.....

[shortnorthstudent]

We chart everything we do in most of the facilities that we are in. Our first term was in a LTC facility and we didn't chart there. That term was learning how to do a Head to Toe and therapeutic communication, etc. Since then however our hospitals are all using electronic charting. As students, we have access to the charting system. Certain things have to be co-signed by oru instructors (specifically progress notes). As far as medications, we do not have access to the pyxis under our own user names. We have to go with our nurse or our instructor to access the medications. However, in most of the facilities, once we scan the patient and the med, we scan our own ID for Med administration. Generally our instructors have to co-sign. Depending on the facility, they either have to do that as we are adminstering or some facilities they can co-sign later. I am applying for a preceptroship, so I do not yet know how access will be then.

We chart assessments, vitals, ADLs, procedures, teaching, I/O, meds, --- everything we do. While our instructors aren't that concerned about us learning specific charting systems, they all seem to agree that it's important to get into the habit of charting everything we do. As nurses, we need to take credit for what we do and a big way to take that credit is to recognize it and chart it. Some nurses are okay with us doing our own charting and leaving it at that. However, in most cases, the nurses will do their own assessment and chart it as well. So, our charting is pretty redundant for assessments and the like, but it is an important part of the learning process.