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starhammock

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  1. I have been charting by exception for about 10 years. Recently our charting changed, we are to cbe in the nurses notes and the chart to the care plan in the physician progress notes and talk about the patient progress toward the overall plan. I find it takes me at least 30 minutes to chart if there are no problems (patient progressing as should). I have to come up with an action plan on how to get my charting done sooner (it usually takes most of my shift now to assess and chart on 10 to 15 patients) because I take longer than anyone else to chart. I find most are not charting as we were told. I tried to email person in charge and was emailed exactly what to chart where. I work where team nursing is in place. I assess and give meds the med nurse cannot give or give pain meds to assist the med nurse. Our unit is a combo Peds and adult med-surg. We have had a lot of new people and can get 10 admits and discharges in a shift. I usually have my patients assessed within 4 hours, but getting it on paper with interruptions can take the rest of the shift. How can we improve this situation? Anyone with any suggestions? Thanks

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