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Discussion

First Job, Nursing documentation

Hello fellow readers, I began my first job a week ago. I am so excited and yet so anxious. So far, I have been only in a classroom setting for my orientation (Going over the new software for nursing documentation). I have not been on the floor yet, but I will be in a few days. I was practicing my documentation through the software and I realize I really need to practice.

I would like to receive advice on how to improve my documentation and organization skills. Other tips and advice based on starting the first nursing job in a psychiatric unit re welcome!

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    • Featured Replies

    Anyone who is brand new needs time to work on documentation. I used to read other nurses notes when I first started. That helped a lot. I also asked questions, lots of questions. Wording is very important in mental health. You will learn as you go. As far as being organized, once you get on the floor, your preceptor will guide you. It's tough to say because it depends on your pt acuity and load. My first job in mental health as a rn, I had 22 pts and oversaw the unit. I'm now in Acute and have up to 8pts. My organization has changed dramatically.

    My advice is to watch and learn. I learn every single day I walk in the door. Respect goes a very long way. I'm not talking about just coworkers, but with your patients. Be safe and watch what your coworkers do in unsafe situations. Listen to your gut. Oh, and don't be on the inside of a room when a pt is standing by the only exit out of the room. It's scary and very unsafe. Been there...once. I will never be there again! Learn lots, congratulations! I love mental health!!

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    Learning the way others document had helped me. I try to peek at as many other nurse notes as I can when I am involved. I am constantly learning new things that way.

    BSN GCU 2014. ED Residency ;)

    Sent from my iPhone using allnurses

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    • Expert

    Absolutely check out the really sharp nurses' documentation and write down the phrases that would be helpful for you to use in future notes until it becomes second nature.

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    • Expert

    Remember to chart what you observe, not what you think is going on. Be objective. Use AEB to back up your statements. For example, don't write, "patient is irritated" because how you do REALLY know he or she is irritated? It could be they are irritated or it could be the effects of the burritos from lunch. Instead, "patient appears irritable AEB patient scowling and responding to me with short, brusque answers."

    When it comes to what patients say, quote whenever possible...and yes, including profanity. You don't need to quote every single thing they say though.

    Chart as though it's going to be evidence in a court hearing. Imagine someone who isn't there reading it and picking your charting apart...does your charting convey the full picture? It's better to chart more than less. It's better to have a lot of detail than gaps.

    Charting skills come with time and practice.

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    I had a list I kept in my badge that read:

    Mood, group participation, interaction, self harm suicidal or aggressive behavior, PRN med school given, and other.

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