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Discussion

Documentation

Hello to all nurses reading this thread.

I know this question might sound stupid.

When is the right time to document nursing procedures in the client's chart right after you have performed a nursing procedure even though it's not your end shift or document it after your shift ( commonly used by my co stuff nurse) yikes!

Thanks a lot in advance.

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    I believe it is best to chart right after the procedure as much as possible. When I leave all of my charting or too much of my charting until the end of the shift, I find that I am more likely to leave things out or run into a "writer's block" as I look at the clock anticipating leaving.

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    I keep a notepad with me in my pocket.

    I chart as I go along, but if I get busy, I can quickly write a time and a couple of words to remind me of what I need to chart later.

    Never wait until the end of your shift to chart if you can help it.

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    Chart right after the procedure if you can or shortly after. But I do know some nurses who wait until the end of their shift to catch up on all of their charting.

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