Do you look up your patient history before taking care of them

[Blackheartednurse]

I'm a new struggling nurse and I noticed that some of the nurses come in 30 minutes before the shift to look up their pt info in the charts,while some just come in right on the clock and proceed to their tasks..I learning to multask in addition to trying to get the basic downs (like dilute meds,starting IV,changing dressing,working with IV pumps,trascribing and reading doctors orders) I find it so hard to just come in right on time and take care of the patients right away (5 minutes is not enough for me to just quickly glance at the chart) I need at least 15-20 minutes to get familarize with my patients medical issues and read doctors notes,but by the time I come in it is time to assess and distribute the meds and go on with the usual nursing tasks...like let me give you an example that happend on my shift that made me realize how important it is to know throughly your patient chart...We had a pt complaining of weakness in her L leg,so neuro consult was notify,they wanted MRI done,but I read in her history that she had a stent put in recently,I notified my preceptor and she said she knew that and she will call the MRI department and let them know..so the MRI people decided it was to early for our patient to have the MRI (usually you have to wait for 4-6 weeks after the stent is put in) so we let the doc know and he ordered the CT contrast..so I'm thinking to myself,what about if I was on my own and didnt read the chart throughly and send patient to MRI,I ,mean this lady's history was long,so my question to you is do you read you chart throughly,do you come in to your work earlier to look up patient info,how early,will I get faster at reading charts (granted I survive orientation),did you find helpful to read chart when you were a new nurse? Gosh nowonder hospitals like to put new nurses on nights,I will working on evening though!

[Blackheartednurse]

I have never come in early to read their history, management would not approve that. But after I received report, I would go and read the first note written after admission, as I found this to have the most complete history including the previous medications taken at home, which helped during med pass when patients wanted to know which medication was for what, and I could explain "oh you took this at home called "ex" and this is similar just a different brand that the hospital uses", patients found this extremely helpful . . .the next note I read was the last note by the MD, this helped determine what new things were going on or if the patient was going to be discharged, helped plan my day much better. I found that if I didn't have all this information, I would have a hard time answering the pt's questions. This also helped in my time management, because the morning med pass would take the longest and it was nice to answer their questions at the same time, instead of trying to come back and looking like I didn't know their history or what was currently going on with them.

Hmm I forgot to mention that I did come in once 30 minutes earlier and it (I believe that it did helped with my performance later that day,the patient wasnt just a room number and the chart actually had a face:D).Of course I didnt clock in..I'm willing to make this sacrafice and come in early for free for the remaining period of my orientation,I mean I'm new what else I can expect,I'm willing to sacrifice one hour without the pay just for the experience sake.I can see how this idea of mines could bother nurses who has been working in this field for many years and have tons of experience under the belt.At this point of my life I'm so overwhelmed with seeing the whole picture that salary is not my priority although I'm not saying I'm willing to starve,but I'm interested in surving these harsh conditions than making the bucks

[Tait, MSN, RN]

On our floor we have these ridiculous 10 page packets for each patients intial assessment, orders and meds. (So, for me, I need time to filter through them). Within that we take time to type up brief "clinical communications" which contain reason for admission and past medical history, plus any procedures.

i.e. (completely made up btw)

Admitted for dehydration.

3-13-10: CT negative r/o DVT

PMH: BPH, Chron's, HTN, GI bleed, anemia, DM.

I personally come in thirty minutes early as part of my process. I like to be at work early (helps with anxiety), gives me a "centering" moment to "put on my RN hat" and get ready to go. I also feel my committment to being early and ready, sometimes 10 minutes prior to shift, has helped build stronger relationships with my co-workers. I respect their time, and understand they have just worked 12 hours and have been very busy.

I personally hate it when the next shift walks in and clocks in one minute before seven, then takes five minutes to put their bags away, and growls when you come to give them report because they haven't had time to look at their papers by 0715.

Tait