Staying late to chart

[crawlyberry]

Hi...I am a new nurse (2months) and I work on a busy post op unit. I seem to be so busy that I am staying late after my shift just to chart. My hospital does not use computers for charting as of yet. There are 4 sheets that we must document on for each patient, and narrative charting which seems to be the thing that keeps me late every shift. I have asked for input from my fellow nurses about time management, etc to help me get faster with the paperwork. I dont even take my lunch break at times, but seem to always stay late to catch up. Is this just the "newbie" in me, or do other nurses find that they often stay late to document? I am feeling very insecure at this point...thanks for listening.

[Penelope_Pitstop, BSN, RN]

i will never forget the first holiday i worked after i was off of orientation. i clocked out at 0915, not 0730. i wanted to never ever come into work again. i had one of those nights, and i literally did not sit down until i gave report the next morning.

was it because i was new? that didn't help. not because i believe new nurses overchart, (i actually think a lot of people chart inadequate amounts!) but because i believe new nurses are just unsure of themselves when charting. charting, even doing flowsheets versus narrative notes, is like no other writing a person has ever done. i don't think my issue was my ingenuity, though. i think i had a bad night. i know that now i would still have ended up leaving late, but i also think i would have not been as late because charting is just easier now that i've been a nurse for two years, not because i'm overcharting.

i have a question for you. why do you not have any time on your shift to chart? i know your floor is busy (you're preaching to the surgical nursing choir right here!) but it seems like the other nurses have some time during the shift (even if they aren't charting as extensively as you and they're more practiced at it, they should still be staying late if the nature of the floor is to blame). are your patient assignments heavier? do you not get a tech? or, do you do the tech's duties? do you find yourself offering (or being offered) to "help" the other nurses?

if you have heavier patient assignments than everyone, that is not fair. i know that the new kid on the block gets dumped with that a lot of times. that was me. guess what i did? i spoke up...and things changed on our floor for the new nurses that came after me. i waited too long to be my own advocate, but all of the new grads who have come since don't have to deal with what i did. if you're not getting a tech and others are, ditto to what i just said. if you're doing the tech duties, good for you. i think it's great to be a team. but that's the thing. you're a team. there's a difference between helping out when the techs are busy, emptying full urinals since you're in the room anyway, bringing in ginger ale because you're on your way with the phenergen, etc., and saying "oh, no, i'll do it!" to every delegatable task. and if the nurses you're working with seem to need "help" when you're around, do help them. but make sure they help you. and there's nothing wrong with saying "after i finish my flowsheet here, i'll be right there" (to non-urgent things, of course.)

off the soapbox....

*~jess~*

[Vito Andolini]

i used to wonder why i was the only one staying late to chart and to make sure the assistants had charted the vs and i&o's. other nurses were getting their breaks (meal, rest, smoke, smoke, smoke) and were leaving on time.

i noticed, though, that they were never trying to call doctors to get orders to treat a new cough, a new onset of diarrhea, or other problems. these calls take time.

i also noticed that they were not charting! talk about liability. i think. i wonder what their defense would have been if it ever had come out that they were not charting.

i just kept doing my charting. don't stress. just be the best nurse you can be and never mind who's leaving sooner or later. you don't know what they might or might not be skipping.

[Vito Andolini]

It's pretty common for it to happen to newer nurses. Keep in mind your manager will pick up on it if it becomes a pattern that you stay late everyday that you work. On our unit it results in counseling and finally disciplinary action if it is happening all the time (the overtime eats into the payroll budget). Make sure you're getting paid for skipping the lunch break though!

And paid for the OT! Don't you dare clock out and then continue working.

[onetiredmomma]

Crawlberry, what are you charting for narrative notes? are you duplicating what you have already covered on a flow/check sheet? Does your facility allow you to chart "by exception"? Try to at least get your flow sheets done after you do your assessments. Then you can do the rest of your charting throughout the day. Med/Surg is so hard. Sometimes I tell people I am in "time out " until I get some charting done!! Also, as someone else mentioned, its good help CNAs by doing vs, FSBS, etc but it is also ok to let them do that work when you need to get to charting! It should also be ok to tell your charge nurse that you can't take an admit/transfer until you get caught up on some of your charting. Lastly, don't skip lunch!!! Even if you take an abbreviated 20 min you need to get away and regroup, refresh to be efficient. Good luck and thank you for joining our profession! (people like me need to know someone is going to be around to care for us as we continue to age!)