Documentation

[NurseNerual, LPN]

I have just graduated LPN school and I am waiting to take my NCLEX. From all my studying I have done this past year I know how important documentation is and with that being said I have worked in clinical with many nurses and know not everything is by the book. At the same time though working in the hospital vs working in a long term care facility I've seen that documentation is completely different (from what I have experienced). My school did a preceptorship for the last 2 months of our program where we had to log in 200 hours with the nurse we were assigned. Learning this facilities online charting system was easy but it always puzzled me as to why you only really chart the medications and if there are adverse effects or pt refusals, basically only things going wrong or if the physician was spoken to (Yes there is extra charting at the end of the night where certain pt have have behavior, ABT, Med A/B, skin checks or whatever is ordered to be charted) and this isn't the only LTC facility where I have noticed this. Where as in the hospital the nurses I saw charting would document the position the patient was in upon entering room and that the call light was in place and there was no signs of distress, etc (Just like we are taught in school). I guess my #1 question is since I haven't had to much experience and i will be getting my first job soon, Does this sound right? Should I only chart what is asked of me to chart? or should I always take those steps when doing a med pass and hourly rounds and state my pt is in high fowlers position, tv on, pleasant disposition , no signs of distress etc. if this is genuinely the case? Also where would I add these little charting notes because for example on this system I worked on for 200 hr, the only place you could type your own comments was "progress notes", would it be acceptable to put hourly rounds charting there? (because like I said none of the nurses I worked with did)

[brownbook]

I have been nursing for 33 years and I am the worlds worst at charting. However I prioritize that my patients are well taken care of and my tasks are completed over my charting being perfect. (And getting out on time...not that I care much about that but management frowns upon nurses staying late to chart and getting overtime pay.....waaaay more than management ever disciplines a nurse for their style of charting.)

I have spent 20 minutes holding a patient's hand and easing their fears.....then only charting...patient alert and oriented vital signs stable. Instead of NOT spending those 20 minutes with the patient and having my charting look perfect.

Honestly it depends on your hospitals policy, type of charting system. and how many patients you have. But it seems that only charting what is asked of you is quite appropriate???

I wonder if charting worries come from instructors saying if you get sued over a patient care issue you're going to be in trouble if your charting isn't perfect?

[NurseNerual, LPN]

Yes I do believe my worries come from teachers stressing the many ways we as nurses can get into legal trouble for charting and where I would never neglect/cut short patient care to go and chart, I just worry about making sure at my very first nursing job I will be charting correctly and efficiently in the case that something happens with a patient. @brownbook

[nursel56]

I wouldn't spend a lot of time of worrying about what your charting should consist of before you start your first job right now. Take the NCLEX-PN according to what you have learned in school and other supplementary sources you might use.

Policies on documentation are specific to the environment in which you work, (specialty, acuity, etc.) and are introduced during your orientation. I will say that it isn't unusual at all for the narrative section to include only things such as a significant change in your patient's condition, what your nursing intervention was, or anything unexpected or not within normal limits for that patient.

You may also find documentation requirements at your job to include flow sheets or check boxes where you document what is required without the need for a long narrative.

Anyway, don't worry and best wishes for success on the NCLEX!

[NurseNerual, LPN]

I have been watching videos aimed towards new nurses and that's really what got me overthinking (like always). I'll just be sure when I do start working to clearing facility policy on documentation.

I know I should be worrying more about nclex as of now or I won't have a first job to start ! Haha

Thank you very much @nursel56