Paper Charting venting

Published

  1. How does your unit/facility chart?

51 members have participated

Hey everyone! I am not sure if I am here to vent or to ask for any words of wisdom. I just finished my orientation at my new job last week as a new grad. I got four orientation shifts in total (as I am casual). While I was running around trying to figure everything out I got good feedback that I was going to do great. BUT my biggest issue is the paper charting. Throughout school we have electronic charting so that's what I am used to. But the paper charting is adding a lot of extra stress to trying to figure everything out. And having to try and read doctor's orders is so hard and time consuming (I know....get used to it). I know a lot of places paper chart, and that used to be the way everything was done, but I feel like I don't know anything because trying to figure out where to find certain information, document certain things, is taking up so much more time than if it were electronic charting. I feel horrible for venting about it as it clearly works on the unit but I am just having trouble starting as a new grad having to learn how to document…Really dreading my first shift on my own.

Up Vote Up Vote ×
Specializes in Psych, Addictions, SOL (Student of Life).

You'll get the hang of it. Being young and raised in the computer age - it must feel very anachronistic doing paper charting. I would not be surprised if your facility is going to go to computer based documentation soon as it is a federal mandate that all hospital charting systems be computerized by 2020 (I may be wrong and it's a year either way) Think about us poor old nurses who did paper charting for years and have to relearn everything with our declining cognitive function and inability to cope with change (just kidding folks).

Most of the paper charts are tabbed in such a way that you will know when you open them which sections you need to look at/write in. Deciphering Doctor's handwriting is always a mystery for new nurses, although some of the younger docs have gotten much better at this. Other nurses can help you with and when in doubt you call the physician, and say something like "I'm sorry doctor, but I'm having trouble making out your hand writing" then read the order as you think it is for the Dr. to clarify. Make a note that you called and clarified with time and date so you have accurate records when a doctor tries to dispute that you talked to him/her. You don't have to do this for every order unless you want really angry physicians but for sure you would want to call if an order was completely illegible or just doesn't seem right to you.

Hppy

Up Vote Up Vote ×
Specializes in NICU, ICU, PICU, Academia.

You are a new grad being turned loose with FOUR orientation shifts?

You have way bigger problems than paper charting my friend.

Up Vote Up Vote ×
You'll get the hang of it. Being young and raised in the computer age - it must feel very anachronistic doing paper charting. I would not be surprised if your facility is going to go to computer based documentation soon as it is a federal mandate that all hospital charting systems be computerized by 2020 (I may be wrong and it's a year either way) Think about us poor old nurses who did paper charting for years and have to relearn everything with our declining cognitive function and inability to cope with change (just kidding folks).

Most of the paper charts are tabbed in such a way that you will know when you open them which sections you need to look at/write in. Deciphering Doctor's handwriting is always a mystery for new nurses, although some of the younger docs have gotten much better at this. Other nurses can help you with and when in doubt you call the physician, and say something like "I'm sorry doctor, but I'm having trouble making out your hand writing" then read the order as you think it is for the Dr. to clarify. Make a note that you called and clarified with time and date so you have accurate records when a doctor tries to dispute that you talked to him/her. You don't have to do this for every order unless you want really angry physicians but for sure you would want to call if an order was completely illegible or just doesn't seem right to you.

Hppy

Thanks for the reply! And I know some people would rather stick to what they know (paper charting) as that used to be the norm, which is why I feel guilty complaining about it.

Guess it's good to learn how to do both!

Up Vote Up Vote ×
You are a new grad being turned loose with FOUR orientation shifts?

You have way bigger problems than paper charting my friend.

Trust me, I know. But apparently because I am casual they don't want to invest in more time training me in case I leave. Which I don't plan on as it is in the field that I've always wanted. Everyone has been very supportive saying to ask as many questions as I need...kind of feel like I'm being thrown to the wolves. Going to have to cross my fingers and hope for the best when I get my first call to pick up a shift í ½í¸‘

Up Vote Up Vote ×
Specializes in ICU.

FOUR SHIFTS??? As a new grad??? Run away from that place. They do not have your best interests in mind by any means and are setting you up to fail. Absolutely no way are you ready to practice independently that soon. What type of facility/unit is this? I'm assuming by "casual" you mean PRN? If so that is no excuse. If the hospital truly cared about you succeeding they would give you the time and training you deserve.

Up Vote Up Vote ×
Specializes in Psych, Addictions, SOL (Student of Life).
Thanks for the reply! And I know some people would rather stick to what they know (paper charting) as that used to be the norm, which is why I feel guilty complaining about it.

Guess it's good to learn how to do both!

No problem. At 54 I'm a bit of a crusty old bat but I am computer savvy. When I was a kid my dad was fascinated by and loved technology. Back in the mid to late 1980's we were one of the first families on the block to have a personal computer. (TRS-80) Texas Instruments AKA Radio Shack . I still remember how big it was and exchanging the big floppy disks over and over as we worked a program.

I do find it a bit funny how terrified many nurses are of computer system change - like we didn't see it coming years ago.

Hppy

Up Vote Up Vote ×

I had a quick look at OPs posting history.

She's in Canada. It's the norm up here to get 3-5 shifts for orientation unless you are hired in a specialty such as Dialysis, NICU, ICU, etc.

Orientation is used as a time to learn the routines of the unit, the flow of the shift, and documentation. For casuals, it is often two shifts per unit they are being oriented to. Usually, new hire casuals are orientated to two units on the same service, so it work out to four days of Ortho.

OP also mentions she's been licensed in two provinces, so that's where I think most of her difficulties would arise. Every province is different in how they do things.

My facility uses a combo of computer and paper charting. Meds are all computer recorded while care is long hand. The chart sections are clearly marked and it's very easy to follow.

Up Vote Up Vote ×
I had a quick look at OPs posting history.

She's in Canada. It's the norm up here to get 3-5 shifts for orientation unless you are hired in a specialty such as Dialysis, NICU, ICU, etc.

Orientation is used as a time to learn the routines of the unit, the flow of the shift, and documentation. For casuals, it is often two shifts per unit they are being oriented to. Usually, new hire casuals are orientated to two units on the same service, so it work out to four days of Ortho.

OP also mentions she's been licensed in two provinces, so that's where I think most of her difficulties would arise. Every province is different in how they do things.

My facility uses a combo of computer and paper charting. Meds are all computer recorded while care is long hand. The chart sections are clearly marked and it's very easy to follow.

Yep, I am in Canada. Went to school in the West and now I am working out East and things are very different!

And I am in Radiation Oncology!

Up Vote Up Vote ×
Specializes in LTC, Rehab.

Wait: reading doctor's orders is hard?? Ha ha ... just had to say that. There have been a few times at work where 2-3 of us are holding a piece of paper with doctor's orders, turning it this way and that, taking our glasses off, saying "I don't know, what do YOU think it says?".

Up Vote Up Vote ×
Specializes in Psych, Peds, Education, Infection Control.
Wait: reading doctor's orders is hard?? Ha ha ... just had to say that. There have been a few times at work where 2-3 of us are holding a piece of paper with doctor's orders, turning it this way and that, taking our glasses off, saying "I don't know, what do YOU think it says?".

I got exceptionally good at deciphering doctors' handwriting in my first nursing job, because one of the doctors I worked with pretty often had notoriously terrible handwriting. This has come quite in handy over the years, but I still end up in this situation now and then, with two of us (there are rarely more available on my unit) squinting at it and pondering. I've gotten used to the pattern of most of our medical director's written orders, so I can usually figure those out fast, and he's the worst of the bad-handwriting offenders...among the doctors. The actual worst, LOL, is actually one of our night shift nurses. I just stare at it sometimes like...what?

To answer OP's question, my facility has been promising us electronic charting for years but we're not there yet. It's all handwritten - and, yeah, it's tedious, but you do get used to it. There's a certain flow to it that kicks in after awhile. Now, granted, if you have an extraordinarily busy shift, that goes right out the window, and you're left charting at the end of it... My advice is to get as familiar as you can with the general order of the chart, what goes where. This will help IMMENSELY with admissions, if you're caught without a unit clerk to put the chart together, and also give you a good sense of where to look for specific things - which saves a lot of time. I do audits, and when I first started at this facility, a post-admission audit (the most time-intensive one), it would take me a good 45 minutes, especially since that includes labeling things that weren't, signature-tabbing things, and putting things that are in the wrong place in the right place in the chart. (For the life of me, I will NEVER understand how some people see a tab labeled "Consents," see a form labeled "Consent for Treatment," and put it under Miscellaneous. This happens...often.) Now, after doing it over and over and getting deeply familiar with the chart order, I average about 15 minutes if a chart isn't really a mess. And I'm down to about 5-10 minutes (depending on the length of stay and state of the chart) for routine audits.

Up Vote Up Vote ×
Throughout school we have electronic charting so that's what I am used to. But the paper charting is adding a lot of extra stress to trying to figure everything out. And having to try and read doctor's orders is so hard and time consuming (I know....get used to it). I know a lot of places paper chart, and that used to be the way everything was done, but I feel like I don't know anything because trying to figure out where to find certain information, document certain things, is taking up so much more time than if it were electronic charting.

Haha....now you know a little about how it felt to switch to computer charting - and I'm by no means computer illiterate! :)

There are plenty of reasons I'd never want to go back to paper - but every once in awhile I feel pretty nostalgic about it. It was just so simple: Do assessment, write it down. It was just "slightly" more straightforward than...search lists of non-applicable things, click. Search another list, click. Search, click. Click, click, click......

Although...those of us with those 4-color clicker pens were clicking away long before computer charting. LOL...

Up Vote Up Vote ×
+ Join the Discussion