charting exact time

floatRN · May 14, 2008

My worksheet for the day is set up like a grid with one box for each hour of the shift. If things are happening fast and I can't chart, I jot down a note of time I called the MD, or time a rapid response was called, if I jot down vitals I always note the time. This helps me remember the sequence of events later when I go to write my notes.

gonzo1, ASN, RN · May 14, 2008

not to sure about how I would chart the situation you are talking about, but there should always be a documentation nurse when a serious situation like this happens. I hope you weren't alone in taking care of this situation. When I have a pt code I usually do the documenting while the other nurses give meds, etc. I simply write down each thing as it is done with the time after it.

For example: called to pt room for unresponsive pt 0130,

code called 0132

md in 0133

pt intubated with 7.5 et tube at 0135

epi 1 mg iv 0138

atropine 1 mg iv 0139

compressions stopped for rhythm check 0142

asystole 0142

of course you document somewhere that CPR was in progress and pt breathing assisted with bag, valve, mask etc

if you are working alone and can't chart just jot down a memory jogger and time whenever possible, then you fill out the chart to the best of your ability and memory

If a time is off by a few minutes it is not illegal or fraud unless you deliberately set out to falsify the record

Hope this helps some

racing-mom4, BSN, RN · May 14, 2008

One nice thing about the unit I work in is the Vitals are tracked on the tele monitors so it shows exact time. So I use that print out to help in my late charting.

When I am doing late charting though I chart in 5-15min increments. Unless it is something that depends on the minutes. I notice though that most of my charting times end in 0s or 5s.

RN1989 · May 14, 2008

In the event that it is not a code where there is someone to chart it I have several options. As I gained experience over the years I no longer kept a clipboard. Now my "brains" for the shift is folded up in my scrub pocket. I can whip it out in a flash to write on. I don't use a pre-printed worksheet but instead I get 2 pieces of blank copy paper that I divide into sections and write my pt's kardex type info on. Then I have plenty of paper left to write on.

Another tried and true method is my arm, both sides with time vs, and meds given if need be if I don't have paper. Grabbing a paper towel out of the bathroom also works well.

Generally I have found that in a code, the recorder is the one keeping track of the time so I have always used my watch's time if I am recording and not a clock on a wall since so often the clocks are wrong (unless the code doc wants to use the wall clock but usually they don't care they just ask you if it is time for more epi yet). For all other charting as well, I use my watch. Can't count the number of times I go into room number 1 and that clock says it is 5 after and 2 minutes later I go into another room and that clock says it is 3 minutes TILL the hour. Nothing is completely syncronized and you can get automatic vs machine times that don't jive with the times on the tele monitor recorder and neither of those jive with clock on the pt's wall. Since I use my watch's time ALWAYS and EVERY time when I am recording, if an attorney were to later question all the time discrepancies I can explain that all equipment is not synced at the hospital and the correct time is the time that i documented according to MY watch.

YellowFinchFan · May 14, 2008

During the event, I was too busy to chart. I just jotted down vitals. As soon as I got a chance, I sat down to chart. In my notes I wasnt sure exactly what time on the clock I noticed the symptoms, or the exact time that I called MD... I just put the closet time possible.

During an emergency situation I jot down the time when I write down the vitals....we use anything (a paper towel is a favorite emerg writing tablet) I always write the times down on vitals , MD in room, etc etc...it's a big help if its not your patient and you're helping the primary nurse who has her hands full.....I've learned to pack my pockets with pens,paper etc...you never know! :twocents: :nurse:

Valanda · May 14, 2008

I have to agree with RN1989.

I often write on the inside of my lower arm.

Just quick notes like time and abbreviation for what happened.

I have managed to lose little scraps of paper too easily, at least if the info is on my arm it doesn't get lost!

Valanda · May 14, 2008

Also, I always sync my watch to the time clock at the beginning of each shift. Seems to me that the clock I get paid by is the one that counts!

Trauma Columnist · May 14, 2008

I take a piece of tape and put it on the front of my thigh and I'm off and running! Works for me. I use this pre-hospital as well.

strugglingnurse · May 15, 2008

Thanks everyone for your suggestions. I will definitely use them next time.

I was mostly on my own during the situation. My pt was stable, all VSS, her only symptoms were slightly slurred speech and a facial droop, both of which I noticed immediately and called the MD. Otherwise, her neuro status was unchanged, A&Ox3, equal strengh in all extremeties, o2 96% on 2L NC,....

Still, there was tons to do, draw stat labs, and of course record e/t. One nurse got the labs for me so I was able to prepare her for transport to CT. That same nurse monitored my other pts while I was at CT. I was so greatful. I sure will be more aware to jot down times.