Failing to Document

Aneroo, LPN · Jul 9, 2005

Do you have a preceptor? If so, talk to them. Tell them you're worried, and you want them to read what you're putting, making sure you're not missing anything. I have mine read over my shoulder to make sure it's all there. We also have a nurse who is also a legal nurse consultant- she reviews charts for court cases. People like that are excellent go-to folks for help. Talk to your unit educator. Because yes, in the end, if you fail to document something rahter important, you could have a lawsuit or loss of license. Remember, if it wasn't charted, it wasn't done. I'm glad you are strong enough to realize this is something you need to be working on- just be sure to tell your co-workers/preceptor/mentor. -Andrea

cursenurse · Jul 9, 2005

your feelings of inadequacy are normal for a new nurse. i can tell you that waiting until the end of your shift to document is a very bad idea. you need to write things down as soon as you do them so that nothing is forgotten. if you are waiting till the end of your shift, your documentation is probably not as good as it could be. if i were you, i would seek the help of an experienced nurse on your unit and have him/her look at your documentation and give advice for improvement. it sounds as if you are having a time management prob. which is common when you first start out. i got over that by priortizing and delegating. make sure that you're not doing things that the CENAs can do, that is a trap that alot of nurses fall into. relax, get a mentor-that really helps! good luck!:)

Tweety, BSN, RN · Jul 9, 2005

Hang in there, as was stated above, what you're going through is entirely normal for a new nurse. It will all come together.

I know the feeling, even as an experienced nurse. I try very hard to get my thoughts together and not save charting until the end. Sometimes you can't help it, but most experts advice to chart while it's fresh in your head.

military girl · Jul 9, 2005

I can totally relate to what you are going through.

My first year out of school was tough, but it does get better. As a RN of 4 years now, I am in a new position and it has been stressful for me. But as far as the documentation thing goes, I agree with everyone, if you can, document while it is fresh in your mind. Saving stuff until the end of the shift can cause you undue stress, and you feel rushed to get everything done, which can result in you staying over to get your work done.

Being a new grad is tough, but it will get easier. In this new position that I am in, I am a military nurse that has not done military nursing before. I come from the civilian sector, so I have a somewhat large learning curve.

Hang in there.

Bijou-Spice · Jul 9, 2005

MissMaryRN-- I just graduated and won't begin working until Aug, so I don't have any personal experience to share but if you do a search on some of the threads you will find some good time management and organization tips.

Some that come to mind are...get a notebook and write down your RN notes right away so you can word it correctly and then show it to your preceptor then you can put it in the chart when you have time plus you will know it is a complete note. Also writing a to-do list at the start of shift so you can cross things off as you go. I know there are others.

Lastly, someone wrote that they stopped being so hard on themselves at the end of every shift when they got home they thought about the day for 10 minutes to evaluate what they hadn't done and then took action if needed, and then enjoyed the rest of the night at home ....relaxed.

Good luck and hang in there, I know I can be scattered at time at home so I have been trying to absorb the hints here to prepare.

PeachyOrthoRN, RN · Jul 9, 2005

I agree with tweety and militarygirl...it will come easier to you as time goes. I've also been a nurse for four years and still ask question when it come to documenting so I get it right.

live4today, RN · Jul 9, 2005

:balloons: missymaryrn...welcome aboard allnurses!!! :) congrats on your success as a new nurse, too!

you've already been given some great advice, so i won't repeat what has already been said. i'll just leave you with a big hug :icon_hug: and some flowers:flowersfo to cheer you up a bit. you'll be in good hands here at allnurses, and get some great advice. it's helped me a lot in times of need, so hang in there. stay encouraged! :)

danh3190 · Jun 13, 2009

I agree with not waiting till the end of the shift to document, but documenting in real time on our computer system isn't very easy. We all have paper "Nurse Handoff Reports" for each patient that we keep on our clipboard. I write brief notes on the back of the patient's paper, (e.g. 1456 - Told Dr. Smith about pt bradycardia of 45, no change in rx.) Then during quiet times I get on the computer and enter my notes into the system. Even in a rush I can just write something like 1300 - atropine. I do try to document in real-time as much as possible though.

RedhairedNurse, BSN, RN · Jun 14, 2009

document by exception only. we have shift assessments and document each system there, so therefore there is no need to type long nursing notes. If you do something, document it, such as vital signs, applied O2, turn q2h, dressing changes, notifying physican, etc. don't double chart.....if you scanned a med and charted in the med computer, no need to type a note.

Don't feel depressed. Look at what other's are typing to get a general idea. It takes time to get your own personal dialogue down but it will come. Quit being so hard on yourself.