newbie charting

[alumno]

Any advice on quick and efficient charting in the OR?

I'm just starting my clinicals and between managing the patient and answering my preceptors' million questions, I'm wondering how others best manage their time to document.

Thanks!

[CRNAGAL]

Try to fill in as much as you can before the patient arrives. Develop a charting routine so that you complete things in the same order each time. Try to write the most important things down first, you can fill in the fluff and details when you've caught up.

[skipaway]

IMO, never pre-chart your important events...ie...induction note, reversal note, extubation. If something happens inbetween those events, you'll have no where to write about those incidents. Also, all those events may have their own complications and you'll have to make those changes on your chart.

I agree to chart what you can...just not those things.

[ICUDOUCME?]

I also have trouble with this until I get used to the new clinical site that I'm at. I try to look at the cases the night before, get the paperwork together for each pt and fill in names, dates, plan of anesthesia if known, meds, procedure, etc. Then, the next day, I can concentrate on just charting the events as they happen.

During the case, if things are going too fast, I will pull up the trends page on the monitor and chart the vitals later. If there is a change in BP one way or the other, I write that down along with the intervention. I just have a habit of grabbing my pen whenever I push a med or change the gas setting.

Often, the post-op orders are similar and you can fill in some of that, I mean, almost everyone gets some form of fluid after the case, pain meds, etc.

[CRNAGAL]

Sorry, I didn't mean precharting events, I meant like filling in your pre-op vitals, pt. history, that type of thing.

[rnbeauty]

I have the same issues with charting. seems I am always messing up the CRNA nice neat chart. So what i did was take an entire anestheisa packet home and studied thoroughly. It made me more comfortable as to what goes where, ect.

Now after a month into clinicals I have gotten a little better. Im not as anxious about the entire charting process.

I also think it depends on who you are with. Some CRNA's can be so mean for absolutley no reason and it make you more nervous, which causes more mistakes and anxiety. Granted, i understand we are learning and it's imperative for us to learn this important material however, it's no reason to treat people like they're crap. I personally think when CRNA's do that it is because they had it tough in school and someone treated them that way or they are just unhappy people and having a rough personal life.