Nursing documentation

[NurseTy6893]

Hey all,

I am a registered nurse on a tele/medsurg unit. My organization is pushing to document all assessments at the bedside. However, with six patients and little time this is not always possible. How can one remember head to toe assessment and not be stuck trying to remember what patient has what. Input is greatly appreciated.

- Nurse Tyler

[JadedCPN, BSN, RN]

Hey all,

I am a registered nurse on a tele/medsurg unit. My organization is pushing to document all assessments at the bedside. However, with six patients and little time this is not always possible. How can one remember head to toe assessment and not be stuck trying to remember what patient has what. Input is greatly appreciated.

- Nurse Tyler

Perhaps I'm misunderstanding. But based on your post, the best way to remember head to toe assessment is to document the assessment at the bedside like it sounds like your organization is pushing. Or document as soon as you come out of the room, before heading to the next patient.

As a newer nurse, I found it easiest to do it this way so that I would remember everything, but it definitely wasn't the fastest way. Now years later I assess all of my patients first before I document, and I jot down any notes I need to on my "brain" sheet after I leave a patient's room before moving on to the next one.

[ICU-BSN]

Another trick is to just document any abnormals or otherwise noteworthy findings at bedside. Then later you can sit down and fill in all of the other WDL items.

[JKL33]

Do the bare minimum as fast as possible at the bedside. If you can't find a good box to click for something you absolutely want to convey, free text it somewhere and move on.

You'll go about 5 days feeling terrible and sucky for not documenting like a nursing student and after that its home free when you realize no one cares what you click.

Ugh. Scratch that, I suppose.

Just do it at the bedside, as fast as possible. Focus on abnormals. Remember: If it wasn't abnormal, it must've been normal!

[Guest219794]

Also confused by your question. The best way not to forget something is to write it down somewhere immediately. Like charting it bedside.

It is probably really worth examining your charting. Are you doing what you were taught? Were you taught by people who initially learned to chart on paper? New world out there now.

Chart by exception. Chart concisely and accurately, and never repeat anything.

[RNperdiem, RN]

Sometimes I have to force myself to chart in real time as much as possible. I know this is time consuming for six patients. I remember paper charting (which I found quicker and more precise than computer charting) for six patients is a lot of charting in a short amount of time.

If the day is really busy. I will chart vitals and a few other areas, and plan to get back to finish.

You don't want to find yourself at noon with nothing charted all day.

[psu_213, BSN, RN]

I agree: either chart at the bedside or write the abnormals down on your brain sheet. I personally did the latter because I never really felt comfortable standing there in front of the pt looking at a computer screen, focusing on my assessment while trying to ignore non-pertinent things the pt or their family members were saying.