Cut corners

I see my preceptor documenting assessments that she simply did not even do. It seems like that is the only way you can "get everything done".

IRL Nursing 101 in a nutshell.

RN819, your story sounds a lot like mine. I was constantly staying late to chart after my shift to "get everything done." I did the full assessment on all of my patients. My floor was so busy it felt like I could never keep up. Time management is huge with floor nursing! My preceptor taught me to try not to be so wordy in my charting, and to start my assessments right after report. Let your team members do as much as they can for the patients so you can get your tasks done. It takes a great team to be able to get through a 12 hour shift and get it all done. Also remember, the next shift can pick up where you left off. Keep your head up! Maybe you should consider a slower paced environment? The great thing about nursing is there are so many different avenues you can explore!

From reading another post about cutting corners, it seems that all nurses do cut corners. So my dilemma is trying to figure out where I can safely do so. I am by the book kind of nurse and I'm finding out that is impossible to do. I'm afraid if I cut corners, there will be consequences where I may not notice that cutting this or that corner is a bad idea. Any suggestions on determining where to cut them safely?

Real world is different than nursing school, only because you'll never have 1-2 floor pts to focus on like we did at clinicals. Heck I remember my first day, with one LTC resident. There simply are not enough hours in the shift to do all that--good care though it was.

That said, you should never chart assessments you didn't do. You'll get the hang of what's truly important, what can wait, and what can be skipped. I mean yes pupil response is part of a full head-to-toe, but do you really need to check pupils on someone who just had a lap chole? Nope. Do you need to listen to bowel and lung sounds? Absolutely. A spiritual assessment might be ideal and mandatory according to TJC, but yes it can wait.

The one and only time I was fired .. was when I called out a preceptor for the very same thing. She never used her stethoscope. She was very good at charting what she did not do.

If you want this position..keep your eyes open and your mouth shut. Get through orientation and THEN practice nursing as you see fit.

Good advice from been there, done that.

YOU do the right thing. P.S. I do not document assessments that I did not do. I agree with Here.I.Stand. Pupils are not a necessity on a typical M/S assessment. In for a neuro reason, ok maybe. Pneumonia? Not necessary.

Get through orientation, and do your own thing. Make sure you have malpractice insurance.

Never chart an assessment that you do not do. Not only is it poor practice, it gets you into significant hot water should your patient have a turn for the worst, or have things going on that no one has seen (ie: skin breakdown and someone charts skin is intact)

This can be found out quite quickly. When a patient develops a hospital acquired complication and the hospital is not going to get paid for it, believe you me they will pick apart every single chart conceivable.

And know that when you do your assessment, and document accordingly, you might find that nurses behind you are going to copy yours word for word.....

"And know that when you do your assessment, and document accordingly, you might find that nurses behind you are going to copy yours word for word....."

This angers me sooo much! These nurses who copy look like they are great while I appear slow and crappy. When in reality, I am doing right by the patient and could lose my job because I am not fast enough. It just burns me up to see nurses giggling and goofing around at the nurses station, I become like the outcast because I am not there "socializing" with them. I feel inadequate, but I definitely am not. Any words of wisdom to deal with this situation??

IRL?? In real life?? Is that what that means?

IRL?? In real life?? Is that what that means?

Yep .

"My preceptor taught me to try not to be so wordy in my charting"

When the requirement is that a note is made on every shift, it seems like charting starts to be the same for every patient. Such as....... "Patient denies pain, no distress noted. Call light in reach, bed in low position." Is that ok as long as that is true for the patient? I feel like my charting for each patient has to be more unique.

Yep .

I guess every nurse just works within their own comfort level as far as integrity goes?? I'm not trying to be Ms. Perfect, I just feel so guilty if I were to make up something just to get the job done.