Need improvement on "close to time" charting and lingo for notes

[GoNightingale, BSN, RN]

Hi everyone, I've been practicing 2 1/2 years. I'm a night nurse Telemetry and Med/Surg Tele, also float to PCU. With the charting system this hospital has "real-time charting" is nearly not possible. I would settle for just getting my shift evals in before midnight or early into the am hours. In most nights, I usually wing up documenting my assessments more into the 4-5 am hours and sometimes- if it has been horrifically busy- after I give report. After I get report which usually takes me into the 1930 hour sometimes 1945, I pull meds for 2000 and 2100 if patient does not have 2200 meds due. If they have 2200 meds due in adddition to 2000 meds it takes up additional time. If the patient has only 2100 and 2200 meds due, I pull them together and- if they are not cardiac meds all put pushed together into these 2 time slots (which I think it's crazy and can be dangerous to schedule them that way)- then I give them together. Sometimes, if none of my patients have 2000 meds, then I do the shift assessments before passing meds. But I do the assessment and I don't have time to document them at that moment. This of course is all based on the acuity of my patient load and the patient load itself-from 5 to 7 patients. Then, when there are no nursing assistants on the unit, I have to do 2000 vitals, Accuchecks and coverage of course). In true PCU units and Telemetry units- with no assistants, we also have to do our own 1200, 0400 vitals and accuchecks for am shift. Between the "computer on wheels" not functioning problems or just plain difficulties (scanner not scanning- big problem! we all know the array of issues with the COWS, WOWS and even the PC's installed in the rooms) and all the patient care (including and not limited to a change of bed linning, cleaning up urine or poop- you know the story....) especially when there are no nursing assistants- which from what i hear, day shift assistants are being cut back or zeroed out on day shift as well. My heart goes out to the day shift nurses! It's not that night shift is not busy (because if you do your job right- it is busy and we just about make it by without ourselves having an MI! Anyway....my med administration is usually late and I usually don't get to sit and start charting until about 0200. I try to put in my shift assessment first. But most of the time, there is an interruption that requires attention (mainly from a patient; i.e., pain medication, can't sleep, took a poop, the list goes on) By the time I get to sit down again...oops another hour has gone by. Now it's 0300- gotta get the chart checks done because gotta know what labs are being drawn at 0500 or 0400, then oops monitor strips to be interpreted and hey I haven't had the time to even look at the course of this patient's hospital stay has been like! Well if I choose to do the shift eval first, the other stuff is behind and doesn't get done until practically 0530-0600 or evenog after! Because.... 0600 meds are due as well Accuchecks for my diabetics! Aya yai! Oy-vey! Dog gonnit! Mamma Mia! Up to now, management has not complained about it because I somehow manage to get it all done by about 0745 or 0800. But you know, knowing what I know today about the powers that be finding anything they can drag out from your performance as an excuse to fire you when they want you out, I really would like to document my assessments as early into the shift as possible. Also just for my own criteria, it looks weird to see on the records that an assesment was done at 2000 that night and not filed until 0300-0500 the next morning.

Anyone out there with suggestions, comments you have found "the secret to real time or close time charting", please share!

Lastly, I find that I have to really think about the way I am going to express shift progress notes, or change of condition notes and end of shift notes. I find that they're great if you want to read a book, but I would like to be more precise and less lengthy about what I document. I've read other nurses notes that have that "note lingo" I have problems with and just state the facts and when necessary, interventions done. If anyone knows of a class that I could take to strenghten my note documentation skills both in accuracy, appropriateness, and legally I would welcome your input greatly!

Thank you intensely allnurses.com community!

[Flame_07]

We have computers in the pt's room so I chart as I go, but this is also a problem to me because it is still time consuming to get to everyones room, then I make a note of the time and have to change the time of assessment in the computer. We have care cast e document and you can change the time.