Forgetting to chart important info

[1jazzynurse]

So 8 hours after my shift ends, i remember i forgot to chart some important info. i'm so worried that i will get into trouble. i think i'm going to have to go add the info tomorrow. today i just felt so rushed that at the end of shift i felt like i knew i forgot to do something. then BAM, it hits me in the wee hours of the am. Does this happen to anyone else?

[CareBayer]

Everyone has done this....I would talk to an experienced nurse (that you have complete trust in) and ask what you should do. We use computer charting that does not allow us to modify information from the previous day. The experienced nurse will be able to tell you if the information does, in fact, need to be charted, and how exactly this should be done.

Don't beat yourself up!!!

[DutchgirlRN, ASN, RN]

who hasn't done this? relax. it wasn't done intentionally. you'll get it straightened out. when i worked on the floor i carried a small notepad in my pocket and wrote down everything i needed to do and made sure everything was crossed off before i clocked out. however, i still occasionally had that 3am uh oh moment.

[UM Review RN, ASN, RN]

It's so busy at the end of the shift, it's a wonder anything gets charted at all.

Lots of times, I follow experienced nurses who forgot to chart for their shift because the patient was unavailable or the chart was unavailable.

It happens, don't stress over it. Try to check your charts over when it 's slow rather than at the end of the shift, and get a system down for marking the charts you've completed. For instance, I circle the room number when I'm done charting on the patient. I red circle the room after I've checked all the orders at the end of the shift.

It helps to have a system.

[1jazzynurse]

thanks. i will make sure i have a notepad handy. i'm also thinking about putting myself on a "schedule" so to speak, until i get into a habit of doing things the way i want them done.

[pagandeva2000, LPN]

In my clinic, we have a patient accountability record where we have to write down the medical record number of the patient we serviced. These sheets have to be turned in to the ADN's office at the end of the month. It happens to be a god-send to me, really, because I write down little burbs on it that need to be charted, and if it was not charted, I place like an X or a star next to it. I got into the habit of reviewing it each evening to be sure that I crossed one fine line under all of my stars. If not, then, I have to chart. We all forget, it is no biggie, really. And, you are still new.