help!!

[sweetieann]

In nursing school, we are taught to chart right as the events are occurring. With today's hectic floors, is anyone able to chart right as the events

are occurring? I remember LOTS of shifts in which I made my first note 12 hours

later at the end of my shift--so busy, I had NO TIME to chart, much less eat,

drink, or pee. Do you make quick notes to yourself and then chart later? Is this

bad? It seems if I chart every little thing "as I go", I'll end up with 30 little notes for a shift, when I could condense. Is it ok to qrite something like this:

ex)say at 11am you write: "At 10am, 650 mg Tylenol given PO PRN for c/o HA pain "6/10"; pt reports decreased HA pain at one hour post. administration "2/10." To monitor"

ps-I'm talking about paper charting! opinion?

Thanks :)

[NotReady4PrimeTime, RN]

It's often not possible to chart in real time. When I am admitting a kid that I know next to nothing about before they roll through the door, I make my notes on the back of one of our blood gas requisitions. Time, VS, who was with them, any monitoring already established, lines, tubes etc. As things are done and changes made in that first hour or so, I write it all down in point-form with the time and later, when I have couple of minutes I sit down and put it all in the chart. I do the same when a kid goes sour and there are a hundred things happening all at once. That way I don't miss anything. When we chart by "late entry" we have to document why it's a late entry, but usually the notes speak for themselves.

[Imafloat, BSN, RN]

It's funny that you ask, because I am working on charting as I go right now. I am finding that by charting as I go, I feel less stressed at the end of the day. It seems like if I don't chart as I go, then I keep reminding myself throughout the day that I haven't charted and it gets me a little more stressed.

[oldiebutgoodie, RN]

As you get more experience, you will be able to chart some things as you go. But it also may not be efficient to do so. When I worked the floor, I took a piece of paper and put 5 columns on it (1 column for each patient). I would jot notes under the column for each patient as things happened, or reminders of "to dos" for that patient. At the end of the shift, I could check that I had done everything, plus pull together my notes for one note at the chart.

Oldiebutgoodie

[locolorenzo22, BSN, RN]

at my work, the nurses have "ship" computers on wheels...which end up making the way down to outside the rooms, and after the nurses get done assessing the patient, they chart in hallway, right outside the room. My hospital also has a computer scan med system, where we have to scan the armbands, meds, armband and chart that meds were given.

at my clinical hospital, I end up having to chart after all my assessments are done.