Behind on charting?

nrsang97, BSN, RN · Oct 10, 2016

I learned to chart as I go. I can't sit down at the end of the day and do all my charting. Can you ask your preceptor for some tips? What system do you use?

Okami_CCRN, BSN, RN · Oct 10, 2016

So, it's my third day precepting, as a new nurse and I'm beating myself up because I had to stay an hour and a half over to chart my narrative. I had 3 patients on my own and my preceptor had two. By 18:30 I was only at 9:00 on one of my patients. I had a wound vac w a PCA a SI pt. and an abusive pt. with Q2 Dilaudud. My preceptor seemed really irritated. And said I don't think you can handle 3 patients. You are really behind. Feeling like poop any thoughts?

I am really sorry that you feel so down. Orienting, especially as a brand new nurse can be extremely overwhelming. To handle three patients on your third day of orientation is a little unreasonable, your preceptor should be up your butt guiding, reminding, and encouraging you to do XYZ.

However, here is my advice; don't be too hard on yourself, but take this time to reflect on what could have been done differently to prevent you and your preceptor from staying late. Maybe you need a fancy brainsheet to organize your care, talk to your preceptor about areas for improvement!

rhernandez748 · Oct 10, 2016

Forgot to mention we are 100% paper charting

Sour Lemon · Oct 10, 2016

So, it's my third day precepting, as a new nurse and I'm beating myself up because I had to stay an hour and a half over to chart my narrative. I had 3 patients on my own and my preceptor had two. By 18:30 I was only at 9:00 on one of my patients. I had a wound vac w a PCA a SI pt. and an abusive pt. with Q2 Dilaudud. My preceptor seemed really irritated. And said I don't think you can handle 3 patients. You are really behind. Feeling like poop any thoughts?

You might want to scale down your narrative charting. If it's already in your assessment (for one thing), it doesn't need to be repeated. Try reading other nurses' notes or asking them to read yours and offer suggestions. Most are slow when new, but you shouldn't be there an hour and a half late unless someone codes at shift change.

akulahawkRN, ADN, RN, EMT-P · Oct 10, 2016

Computer charting or paper charting, try to do it as you go along. Some things may have to wait for while to be charted, but on the whole, try to get to charting throughout the day. Back when I was an EMT, I would do all my charting (yes, on paper) at the end of each run. By and large, it wasn't too bad but I only did the bare minimum during the transport itself as far as charting was concerned. This led (quite often) to me having to sit down and do my charting at the end of a shift and when you've got 9 or 11 patients to chart on, that can take a while. I struggled with this for a good year or so and as I found my way through Paramedic School, I learned to do a couple of things, one of which is charting as you go and the other thing is to develop a basic framework for charting so all you have to really think about is certain specific details that you plug into your framework. Saves a LOT of thinking/remembering and you go fast because you already know most of the "script" you're using.

I went from usually being 3-4 charts back (sometimes worse) to being basically done and turning in my charts when I pulled into quarters at the end of the day because all of my charts were complete because I'd completed them as I went along. Life became much easier.

Now I work as an ED nurse and the vast majority of my charting is complete when I "move" the patient from a room to "out of department" status. I spend my time getting the room ready for the next patient and often I get another patient within 2-3 minutes of that being done. Consequently I may not be able to complete a chart through the entire "discharge process" until much later. This has resulted in "my" patients stacking up on the status board for a few hours. My preference is, of course, to NOT allow myself to get too far behind. Most of the time, while I'll see >15 patients/day, I'm caught up on all my charting.

Just chart as you go along and you'll find that most of the time, you won't be too horribly buried in charts to complete.

Oh, and being 3 days into precepting and being hounded about getting your charting done as if you've been there a while is simply expecting too much of you if you've never worked with 3 patients (or even a full-load) before.

Summer Days · Oct 10, 2016

Take blank paper charts and bring them home with you. Study them, especially the rows you are likely to fill out. Practice narrative writing when you are home. Be familiar with your patient population and the skills you do the most. If at all feasible, bring the paper chart with you to pt's room. Whichever skills you perform while in that room, do not leave the room w/o having documented them in the chart. Try it. At first you will feel slow, but once you get the gist of it, you will surprise yourself at how fast you chart. All the best.

allnurses Guide · Oct 10, 2016

Forgot to mention we are 100% paper charting

Eww-www-wwww!!! Been there done that! Pretty recently in fact. SO glad to be back

to all-computer charting! Your hospital is WAY behind....

3 patients all to yourself by day 3? What type of floor do you work on exactly?

Your preceptor is pushing you a bit too hard, too fast IMO.

NurseGirl525, ASN, RN · Oct 10, 2016

My first week, I was there 1-2 hours over every night. Why on earth your preceptor would say that is beyond me. Especially if you were charting 3, 100% on your own.

Now, I can chart much faster. Some days, I may not sit down until 4pm to chart, but, I can knock it out in an hour.

Be patient, you will get there.

martymoose, BSN, RN · Oct 11, 2016

yeah the q2 hr pain person didnt help matters. sorry.

yes try to do what you can on the run. Not sure what your paper charting requires( i wish we had our paper charting back= it was better than epic) .

If there is routine stuff, like fall scales , iv access, etc, i try to do those before i see my pts right after report, as long as pts are stable.Then you have that much out of the way when the poop its the fan.