Student Charting?

kellyo, LPN · Jan 19, 2005

We're supposed to start this semester. Clinicals start in a few weeks.

stressgal, RN · Jan 19, 2005

We began charting during our clinicals second quarter.

lisamc1RN, LPN · Jan 20, 2005

We were constantly learning charting during our Nursing Fundamentals class. At skill labs, we would do a competency and then chart what we did. The last chapter we studied was totally about documentation. Now that we do clinicals, we chart every 2 hours on our patient.

Never_too_late · Jan 20, 2005

We were constantly learning charting during our Nursing Fundamentals class. At skill labs, we would do a competency and then chart what we did. The last chapter we studied was totally about documentation. Now that we do clinicals, we chart every 2 hours on our patient.

Same thing for me.

N_T_L

Altra, BSN, RN · Jan 20, 2005

When do we learn (ie practice charting)? We do tons of care plans and other things, but we haven't really focused on charting. I know that charting is an essential skill. Has anyone had any practice in school or during clinicals? Or is this just something we really learn during orientation to our first RN jobs?

I think this is something you just have to do repeatedly until it becomes second nature. Will you do more charting in a later semester? How are your nursing interventions charted now when you have clinicals?

We chart pretty extensively. Narrative notes have to be written on scratch paper first and checked out by our instructor.

I do think that, wherever you go to work, part of your orientation is devoted to charting methods used by that particular facility, so you should have a chance to pick it up then.

RN2Bin05 · Jan 20, 2005

Hello babyrn06,

In our program, the way MLOS described it is how we did it too, and we started charting in second semester in the ADN program. So far, all of our hospitals still used paper charts, except at the VA where they were all done on the 'puter.

ttyl....Mitchell

HappyNurse2005, RN · Jan 20, 2005

it was first or second semester( i dont remember anymore) we went over all the different types of nursing notes and how to write them and began writing them at hospital. before putting them on pt chart, we wrote them on paper and had them evaluated by instructor and now in 4th semester completely write them on our own.

SarasotaRN2b · Jan 20, 2005

On another thread, there is a book in the incredibly easy series for charting. It might give you some pointers.

Kris

manna, BSN, RN · Jan 20, 2005

Last semester, my facility did computer charting - so we charted on any procedures we performed (IVs, dressings) and meds. This semester, we're required to sign the MAR for our meds, and we chart nurses notes and turn them into our instructor. We fill out a graphic of what we've done (baths, vitals, etc) and the nurses or instructor document that.

abundantjoy07, RN · Jan 21, 2005

It seems like most of you guys have started charting...

I think I will look into the charting book mccn...I love that series of incredibly easy books. Just incase we don't start soon I'd better get started myself.

Thanks for the replies!

wonderbee, BSN, RN · Jan 21, 2005

We're not permitted to chart nurses notes in the actual patients' charts except for I&O, meds and VS. In second semester, we had a clinical instructor who taught us how to do a comprehensive narrative that we would write as part of our care plan that we turned in to her. Now in third semester, our charting is the PIE format and is expected to be more sophisticated. It's a skill that, no doubt, your school will introduce you to at some time. Documentation is so important in this sue-happy culture we're living in.