How can new nurse be sure of her charting ?

[jollygirl098]

I am a new RN on med-surg floor. I have my preceptor who thankfully is very helpful and understanding.

Defintely our day begins with taking in reports from night nurses. We are very vigilant on meds but throughout the day we do lot of patient care changes, like someone is going for chest x-ray, someone's blood work is being done,dc foley, new doctor orders and we get time to chart everything towards an hour befor the end of our shift. After being so cautious, I found that somewhere in afternoon yesterday I gave pain med/narcotic to my patient and forgot to chart. I charted it just half an hour before the end of my shift but I was so scared so much that it was narcotic meds and i forgot these ones. Is there any way to remember everything by the end of the day. Some checklist format or tips. Anything is appreciated

[meandragonbrett]

Chart as you go/do something. Don't wait or you will forget!

[apocatastasis]

For sure. Try to chart as soon as you can, particularly the important things like turning and meds. Also, don't be too hard on yourself, you are going to make mistakes, everyone does.

[nicole109]

Agreed--chart as you go, and give yourself time to come into your own, you will find a system that works the best for you, and it may not work for anyone else, as long as it works for you and doesn't break any rules, that's all that matters. When I worked in the hospitals, there would be 4 nurses, and each of us did things 4 totally different ways, but all of our patients got taken care of and everyone was happy...you will find what works best with you, and things can be very overwhelming in the beginning...this sounds terrible, but use and abuse your preceptor now while you have him/her, ask questions, get your hands on everything you can, etc. because once you are on your own you will really miss them!

[ivorybunny]

As the others have said, try to chart as you go.. however when things are going crazy, or there's just a lot going on... I write it down. I keep a log on my report sheet of things that happen so that I can make sure I chart everything. You will find a system that works.

[dudette10, MSN, RN]

I asked this of one of my instructors in school. I would check with your hospital policy on note-taking while delivering patient care and what to do with the notes at the end of shift, but my instructor said that she always makes notes as she goes if she can't get to the chart. Then, when she does get to the chart, she charts what she did with the time of the event, but also writes that she is actually charting at a different time. She said she also shreds all her "notes" at the end of shift before going home--VERY IMPORTANT!

[diane227, LPN, RN]

I carry my nursing notes and my MARs with me and chart as I go. If you can't do that then come up with your own form where you can check stuff off easily or make a quick note so you don't forget to chart it later. Everyone has to come up with a system that works for them depending on the environment that they work in and what type of documentation system they are using. If you are doing computerized charting, you have to have enough terminals to accommodate everyone who needs to chart.

As the charge nurse I have a very formal way of keeping track of all the patients and what is going on with them, who is coming and who is going. If anyting disrupts my system, it really screws me up for the shift. You will figure out a system that works for you. If you coworkers have a format they use, try theirs and see if you like it.