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krunchie_07

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  1. Need help with documentation

    krunchie_07 posted a topic in First Year After Licensure
    Hello everyone! I just recently graduated and started working as an RN in a medical acute floor last July 4th. It is already been a month and still I do not feel confident that I am documenting everything as I am suppose to. I always ask my preceptor to review my charting and documentation every now and then to see if I am doing it right or if there is anything missing and she said I am doing fine. But I still do not feel confident and I cannot understand why.I need your help what makes you confident you documented everything. We do an hourly rounding, do you thing I should document it on the progress notes everything I observed even it was the same as the last hour? My preceptor do not think so, I need another opinion on this too please.

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