DalmatiaRN

We are moving to Epic documentation later this year with computerized physician order entry. I have been practicing real-time charting for about a month now and it is challenging. I am looking for some tips to become more successful. Currently we do not have computers in patient room, but 1 PC per 2 rooms outside the door. Adding computers and barcode scanners to every patient room is part of the plan for launch time. I am trying to tell myself that everytime I walk out of that room there is something that I need to chart, whether it be an I/O or a PRN med I just gave. Any tips, tricks, etc that anyone can share to make this transition more successful?

When I was a new grad I took a position on a unit that was poorly managed, had ridiculously high turnover (see training 25 plus new nurses a year), and poor morale. Although I learned an incredible amount and enjoyed the patient population, I was absolutely miserable. By accepting the position I was able to get my foot in the door and within 6 months I transferred to another unit and could not be happier with current management and my coworkers. I did what I needed to and had an exit strategy. I knew going in that I would not be happy and tried to make the best of a bad situation.

I work with an amazing group of hospitalists. Whenever I have an issue that arises with a patient they are quick to respond and will also check back to see if any intervention they ordered is working. Often times when a primary care doc is the attending rather than a hospitalist I can sometimes wait hours for a response to a page for uncontrolled pain etc. Typically the hospitalist responds in minutes.

I'm on a surgical ortho floor and love it! I have a great team and I love the surgical population. For pain control we use scheduled oxycontin 10-20mg typically and then for PRN we usually have available percocet, norco, and toradol. I have to say Toradol is a favorite, but it is hard on the kidneys. Typical issues you will deal with is blood pressure/nausea/pain issues POD #0 and #1. It's not unusual for a patient to have scheduled pain meds, PRN narcs for AM PT/OT and a load of BP meds all scheduled together. Beware :) Different MD's have their own bag of tricks. Anticoags like warfarin or Lovenox or both are common and SCIPS protocol is something you will want to become familiar with depending on your facility. Drains of all types are used depending on MD preference. We rarely ever use PCA's for our orthos. Of course you will wants to review hip precautions etc. :) Good luck to you.

Wow! This sounds so much like my floor! For a moment I almost thought we worked together!

15-2330 I'm sure I'll bring in the New Year giving report.

Have not heard of this at all.

I read that post and it felt like I wrote it! We have the same thing happening and it's ridiculous. I cannot make any plans because I never know when I am working. The schedule is NEVER ready until that a week before it starts and I am never working any of the days I self-scheduled. We have lost more that 20 nurses so far this year and this is what has contributed to that along with high nurse to patient ratios with high acuity patients. The stress level is maddening and most of the new nurses aren't coping.

I have these dreams too. Usually I'm trying to see all my patients and in the dream state I just can't make it to their room. Odd I know. I will try some of the suggestions above. I really think it is robbing me of my deep sleep.

Wow, I feel like I had the very same night and now have to go back and do it all over again!

On my unit we deal with a lot of backsurgery - which means PCA's, epidurals, and LOTS of pain management. In addition to this constant flow we also get ICU transfers such as crani's, bleeds and such. When we have open beds then we will take medical overflow. Ours is a fast-paced unit, but you learn a lot! Ratio 1:6

We have 5-6, and your right, it is HARD! Even if this thread was started months ago, it feels good just to post! Thanks for the little vent.

I have this same issue. All of these calls from random "friends" and "family". I have no way of knowing whom I am speaking with and the questions are always , "How is X doing?" Then this always leads to " Have there been any test results?" What has the doc said?" How do any of you respond to these? I'm still new and my generalizations I fear come off as insincere, I'm not even sure if I'm allowed to make generalizations. I've asked others where I work and get a basic "use your nursing judgment" answer.

I have found all of this very helpful, old and new. Thanks to all of you that have responded.

I work on a neurosurgical floor. Our population usually will have a back brace or a cervical collar (soft or hard) fitted for use post-op. It is added to the chart whether or not the brace is in the room for the patient. Rather than saying hard cervical collar the secretary was trying to type hard one, what ended up displaying on the chart was "Patient has hard on in room."