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Discussion

Help! In Desperate Need of Charting Tips

I'm 8 weeks into a 16-week ICU orientation. Per my preceptor, charge nurses, and ICU directors, I am advancing faster than normal and I am handling the stress well. I LOVE ICU, and I feel like I'm really blossoming. My main obstacle, as so many of you, is charting

I've been told I'm a fast charter and I do have previous experience charting, both as a CNA and a pharmacy tech. I've had several very, very sick/unstable patients and, even when I start my day all caught up in real-time, I find I'm staying an hour or so to chart everyday. I spoke with my preceptor, who says this is more of a situational issue than a personal issue. She states it's been circumstances out of my control that's put me behind, and not necessarily lack of time management.

I get to my unit an hour early to get info on my patients and print strips. I begin my care plans as early as possible, always before 1000. I chart vitals, I&Os, and physican calls in real-time. My main struggle is my head to toe assessment, filling in the blanks, completing our restraint flowsheet, etc. It just takes forever.

Any tips to work smarter, not harder? For reference, my facility uses Allscripts. I'm not looking for shortcuts, but there HAS to be a better way.

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    It’s a difficult charting system. Why do you go in an hour early? Are you being paid for it? It takes 10 seconds to print a strip.

    I just organize my day from the get go and go from there knowing it’s going to get crazy at any minute. I try to at least keep up on my vitals.

    On a good day I like to have my 0800 assessments in by 1030-1100. It rarely happens, but it’s my goal.

    i have a clipboard and keep all of my patient’s info on it from my assessments and I and o so I have my information to chart. I get all of my patient care done first. Then, if I need to I take an hour of uninterrupted time in the late afternoon to do nothing but chart. If I have all my info on my sheet, it doesn’t take a ton of time. There’s just so much double charting with that charting system and no copy and pasting.

    My other question is, are you over charting? Are you writing lengthy notes? Care plans should take 5-10 minutes tops. I prioritize my assessments, med passes, turns and oral care, baths, clean ups, catheter care. I chart when I can, but my clipboard holds all my info.

    Sometimes I am late with charting. It just happens in the ICU. People start crashing, new drips get orders, you are constantly communicating with family and doctors. I get done what I can.

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    6 hours ago, LovingLife123 said:

    Why do you go in an hour early? Are you being paid for it? It takes 10 seconds to print a strip.

    My other question is, are you over charting? Are you writing lengthy notes? Care plans should take 5-10 minutes tops.

    I probably am overcharting and I'm trying to get better, but as a new grad, I'm terrified of missing something important. A lot of times, there's big changes during the day. A sedated and ventilated patient with a tracheal tear is much different at 0800 than at 1600 when they are extubated, A&O, and now vomiting with a ridiculously high chance of aspiration.

    And I go in an hour early to develop the stories on my patients. I've had several issues with nurses giving incorrect reports instead of saying, "I don't know," and it's had bad patient outcomes. I do it to cover my butt and it makes my day a little less hectic.

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