Expert Opinion on Time Management, esp. for DOCUMENTATION

[dulexsidlex]

I have been hired, as a probationary employee, in a telemetry unit. The work can be manageable but I urgently need your expert opinion on time managament. The MAIN ISSUE that I have with me, is the DOCUMENTATION process. With the MDs running around and wanting their orders to be carried out, and patients waiting to be attended, I have less time in DOCUMENTATION. We use APIE, which stands for A-Assessment, P-Planning, I-Implementation and E-Evaluation.

Is there a need to make a long nurse's notes, with the unnecessary details to be included, such as: established rapport, initial assessment done, attended to their needs and queries made...IF, you apply them to all your patients? I mean, we do all of these tasks to our patients but do we have to document them one by one? My preceptor had told me that you have to jot down the things you have done, even the MDs that made their rounds, for legal purposes. So, I had to write the unnecessary details again and again to all my patients.

I HAVE BEEN THINKING ABOUT FOCUS CHARTING, you document the things you did to intervene the observed problem. I URGENTLY REALLY NEED YOUR OPINION AND GUIDANCE!