forgetting to chart before end of shift

[newRN1272]

So I am a new grad (graduated in May 2009) and I just started in October on a Med-surg floor. Things have been going pretty good so far but this morning I woke up on my day off and realized that I forgot to chart PRN tylenol on one patient and the time that I discharged another patient. I know that this seems like pretty simple things and you are probably wondering why I am freaking out but I am still on orientation and still learning and really want to impress my manager ( i don't want to get in trouble or fired!). I am also fairly certain that the 2 patient's charts and information will not be available to me tomorrow when I go back to work - so i can't even late chart for them.

Any advice on what to do? Should I call up my floor and let them know or should I wait until tomorrow to see what happens?

Any tips on how to prevent stupid errors like this?

Thanks for listening to my rant.

[Jules A, MSN]

Two questions for you:

Did you sign off the Tylenol on the MAR?

Did you do a discharge note on the patient?

[newRN1272]

1. I completely forgot to even mention the tylenol and didn't record it on anything.

2. I did everything else for the discharge (note, had the patient sign the releases, etc.) except document the time she left (which is apparently a big deal at my hospital and my manager gets upset about the littlest things).

[caliotter3]

I woke up from a dead sleep at 10:30 am one morning after getting home from night shift. I sat bolt-upright in bed, and remembered that I had not given the first dose of an antibiotic that the PM nurse had told me about as an after thought. I immediately called the day shift supervisor and she said not to worry that she would take care of it, which she did. I never heard anything else about this. If it is something that should have been done, or an important piece of info, I would call. If it is something that you can't take care of until you come in again, like charting, I would just take care of it when I came back in. At least you are conscientious enough to care.

[Jules A, MSN]

Got it. Well this isn't going to help you for this time but if it happens again in the case of not charting a medication as soon as you remember you need to immediately call the floor and tell them. While the Tylenol probably isn't a huge deal as you can imagine if medications aren't charted and double doses are given it could be fatal. Do you have to sign the medication out of a Pixus etc.? Is there a record of it being taken out of stock?

I write all PRNs down on my scrap paper because that way I have the dose/administration time handy in case a Doc asks and for when I chart on the patient. That is a good way to double check yourself before you leave the unit. The good news is that I found that the longer I worked as a nurse the more able I was to remember the meds I've given without much problem.

[newRN1272]

Thank you so much for your help. It was just killing me this morning. I am usually good about remembering and recording things. I was also being rushed by my preceptor and i think that effected my thought process. If the patient is still there tomorrow I am going to try and record it. As far as the time thing goes, hopefully it won't be an issue tomorrow. I think i just needed to get it off my chest - thanks for the help!