helps for charting.

[jackel]

I'm looking for helps in charting. I'm a NEW nurse and I work in a very active ED, But we do not have a tri-fold or computer to help jog my memory in the areas I need to chart, Its just a blank flow sheet to start you off. Please does anyone have a sample charting or guides to help with better charting. Thanks Jackel

[candyndel]

Very well seasoned nurses also share your opinions and frustrations about charting, too- so know you are not alone. If it was so easy, there wouldnt be lectures, conferences and books on it, right??

I actually began ED nursing when our charting was done on a plain sheet of paper, too. It was actually much easier!! Switching over to EMRs was difficult!

I cant stress how important 'good' charting is...having known many nurses subpoenaed and having a med/mal attorney for a sister biases me slightly, though...

I think with experience comes knowing what is important and what isnt. And you are def on the right track!!

This is really good advice, and I try to do this, but I just don't have time to document it all. In my ED we don't have EKG techs, we don't have nurse's aides or ED techs the majority of the time. We don't have IV start kits. We often don't have working BP cuffs/monitors. We don't have computerized documentation.

I feel like I just don't have time to document everything I should, so that's why I just do a more fucused assessment. Of course, the sicker the pt. the more I will try to document.

Documentation, to me, is perhaps the hardest part of nursing. There is a constant fear of omission, yet I don't have time for inclusion.