Hello my fellow nurses! As a new grad RN (who recently passed boards) entering this profession during a time of a "sue-happy" society, I am fearful of not only ultimately making mistakes as I learn but also of being sued. I've heard many a horror story regarding the smallest mishaps during the "shift from hell" but am trying to be more proactive instead of passive in my first year of practice. So, I am asking all of you, both veteran and new nurses to share/trade your best "CYA charting tips."
I'll start with a few of my own:
Even though my hospital is moving toward a paperless charting system with everything being on computers with lists & lists of checkoff boxes, I always find myself wanting to chart certain things that just do not fit into a "pre-arranged" list of check boxes ...
1) when I have a pt with an NGT who is on tube feedings and/or receiving meds, I always chart that I checked for placement by auscultating an air bolus and that I checked for residual prior to administering meds
2) For safety risk patients, I like to chart that I oriented pt to the call light, room, and left bed in the lowest position possible
... that's all I have for now. I'd like to hear from you .... thanks!!!