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New grad...forgot to document

First Year   (578 Views 2 Comments)
by DH1234 DH1234 (Member) Member

762 Profile Views; 23 Posts

I am still on orientation, and I feel like I am still forgetting to document some important things. For instance, one of my patients had a PCA pump and we were supposed to document the settings and his RR every 2hrs. I stayed on top of my charting for the most part. But i forgot to document the one at 6 am because I was so frantic trying to get all my pts meds passed before shift change I seemed to have forgotten. However, I did get his RR with his vitals at 6 am and they were fine. Also, we have to a dual sign off on the pump during handoff. 

 

Do you think this is a huge mistake that I can possibly get written up for or fired for? Sometimes it just hard for me to keep up with assessments that are q2.  Also, do you have any advice on how to stay on top of things like this?

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1 Follower; 686 Posts; 6,895 Profile Views

So you got what you needed but forgot to chart it in 2 places?  Unless your manager is an ogre, you are fine. 

Remembering all the crap you need to chart is hard at first. I made a list and crossed things off as I went until it became more second nature to me. 

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