I don't like charting.

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Specializes in LTC/Behavioral/ Hospice.

I just finished my second clinical day and it has been a real eye opener. We were assigned our patients and told to do a skin assessment along with the ADL's. I absolutely loved the contact with my patient. He was a very pleasant man to work with. He was oriented to name and was very patient with me. I made a mistake because I forgot to use isolation precautions on him at the first. I totally missed the big red stop sign beside his door. :imbar Anyways, once the nurse came in and gave me a gentle reminder to gown up and put my mask on, all was well. :) I even noticed a new Stage I decub on his foot. He was ordered a bed crib.

Every 2 hours, though, I had to chart everything that I did. First of all, it is something that doesn't come easily to me. I can't seem to get a flow to it. It's all choppy. Second, I don't want to be sitting there charting when I could be with my patient! :rotfl: Third, it seems to take an awful lot of time. I keep wondering exactly how much time am I going to spend charting and documenting once I have more than one patient? At the rate I'm going, I will need to do a 16 hour shift to complete all of my work! :uhoh21: Ok, ok, I KNOW that I need to chart. It's a big part of my job. I just don't like it. Do you think that this might change with time?

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Welcome to the club!!!:rolleyes:

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I remember charting my first days on a unit when I started working there.... It was computer charting and took me at least an hour to chart an assessment on one person. You get used to it and becomes more second nature. I can now chart full assessments on two patients in about 10 minutes. :)

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Specializes in Education, Acute, Med/Surg, Tele, etc.

Practice practice practice...it will come easier in time. I too was like "okay at this rate can I even look at my patient for more than two minutes?!?!?!". But after doing it for a while...I got my own routine and got it down to no time!

I am still accused of charting too much, but if there ever is a question or lawsuit, my charting will be one of the better ones! The thing that gets my other nurses is how fast I do it, and they can still actually read my writing..LOL! I just do a form of SOAP charting every time...a condensed version...and it really goes much quicker with a format I can do quickly and get it all down!

You will get it...just like you will with making assessments quicker and still cover it all!

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Who does?

Seriously, I don't know anyone who *really* enjoys it. Wherever you go, you'll develop a routine for documentation and you'll be fine. Its harder in school because you jump around to a bunch of facilities (at least I did) and documentation is different everywhere you go.

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Specializes in LTC, assisted living, med-surg, psych.

As the saying goes: Documentation does not improve our nursing care.......it PROVES it. :)

Just think of charting as giving yourself credit for all the good work you do and the observations you make during the course of a shift. And if all else fails, remember: IF IT'S NOT DOCUMENTED, IT WASN'T DONE :rolleyes: .

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Specializes in Utilization Management.

I once calculated that I spent more than half my shift doing chart checks, charting, reading docs' handwriting and fixing errors from other shifts.

Nope, not fun. But necessary. :o You'll get faster at it. A good book on charting essentials can make you more efficient too.

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Specializes in ER/Trauma.

Hmmm, seeing that I will soon be thrown like fresh meat to the wolves :p :

A good book on charting essentials can make you more efficient too.
Anybody got any suggestions on this? :)
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Specializes in LTC, assisted living, med-surg, psych.

Yes! Try "Charting Made Incredibly Easy", it's one of many books in a series called, not surprisingly, "Incredibly Easy". You can find it at any major bookstore, e.g. Borders, or you can purchase it online. These books are actually fun and easy to read, yet they cover complicated topics such as fluid and electrolytes, EKG interpretations, critical care, and so on.

:)

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Specializes in LDRP.

it gets faster as you get used to it. you say it is your 2nd day in clinicals, if you mean your second day EVER in clinicals, then you have plenty of time to get faster. and you do. you get used to the system, you get more comfortable with what needs to be said and how to say it.

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I worry the most about my nurses notes. I don't agonize over the flow sheets. I try to alway mention any teaching I did and do problem oriented nurses notes.

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Thank you! I appreciate these little hints. Though I have a while to go, it is never to late to be aware of what is coming up.

Kris

Yes! Try "Charting Made Incredibly Easy", it's one of many books in a series called, not surprisingly, "Incredibly Easy". You can find it at any major bookstore, e.g. Borders, or you can purchase it online. These books are actually fun and easy to read, yet they cover complicated topics such as fluid and electrolytes, EKG interpretations, critical care, and so on.

:)

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