The New Grad & Charting

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i'm a two week old new grad!

in clinical, i was only exposed to "click click" "scan scan" computer charting, and making "clinical notes" as needed.

the tele floor i work on is a whole different way of charting.

it is our policy to chart by exception. the main part of this that i'm trying to get a good grip on is the 24 hour flow sheet and the nurses notes.

initially, i was trained on the way to open my note with things like vital signs and abnormals. gradually i've seen on an and by coworkers - don't double chart things like vs on nurses notes and on the graphic sheet b/c if a discrepancy was created on accident, it could knock you credibility in a legal arena. so, i started to get more careful.

on our 24 hour flow sheet, if something is "abnormal" we are to make a nurses note entry about it. usually if its weak pedals i'll say "bilateral weak pedals noted, skin warm and dry" if its adventitious breath sounds i'll say such "posterior bilateral lower lobes decreased, pt denies sob, resp even and nonlabored." those are things i'm okay with and come up with wording, state what i see.

lately, i find i'm staying at work till 9pm-10pm after shift trying to finish up charting because so much happened during the day, 2-3 discharges, 1-3 new admits, pain relief requests, pts receiving blood or returning from cath lab requiring q15 vs that i get so caught up in rooms that i get swamped with charting entries.

that's my goal #1, is to be more efficient at charting during the shift. my goal #2 is to learn more lingo to chart. (point of this thread =] )

i've read things like don't say "pt resting comfortably in bed, resp even and nonlabored" because how do you know the pt is "resting comfortably?"

i've had preceptors tell me "if something is not there or is not observed, such as you don't hear a murmur then don't say anything about it because what if you can't hear it? only say what you can assess, observe and what the pt states." it can be confusing. there are other cases where a preceptor has told me in reference to a c/o of 10/10 chest pain to notate "hob at 45 degrees, no facial grimacing noted, pt requests snack" (which was the case) those are the entries that don't immediately pop into my head as something to say.

so here are some questions i have..

- if the flow sheet has "pt safety check" on there and the option to check boxes for resp even and non labored and option to check for no c/o pain, would you use the flow sheet or nurse note q1-2h?

- if you gave a pain medicine at 1200 and at 1245 the pt is "sleeping" do you wake them up or do you entry "pt in bed with eyes closed, resp even and nonlabored, no signs of pain observed?" --- what signs of pain are you looking for a in a sleeping person? facial grimacing?

- if pt refuses to wear ted/scd/tele, i make entry and state education offered, verbally explained, needs reinforcement, those sorts of things.. do you call the md or do you wait for rounds?

i know part of it is i'm a two week old baby nurse and have a lot to learn. i read a bunch of threads on charting on here, i hope if the things i brought up on this thread will provoke some new thoughts, suggestions, from experience point of views on these types of charting entries and how to learn when you can make time to chart.

advice to get more efficient? advice on charting entries you've made or seen that could be better or worded differently?

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Specializes in Dialysis.

I bought Mosby's Surefire Documentation - How, What, and When Nurses Need to Document.

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Thanks for responding. I looked at that book and a few others. Good information, I am hoping for some personal insight/experience with charting though.

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Charting is a learned art, and when I was as new as you are, I was staying over that long as well. Your best bet is to chart right after something occurs. If you have 30 seconds, make a note. This will keep you from forgetting things as your shift progresses.

If your flow sheets are legal documentation, I would say that you can use the flow sheets. That's why they are there- to keep you from having to chart the same thing every hour or two.

If your patient is rating pain 8/10 at midnight, you give the PRN, and they are sleeping at 1245, that's an indicator that their pain is relieved. He's not tossing and turning, groaning, grimacing, or otherwise showing what you would describe as pain. I would definitely chart that patient is resting quietly with eyes closed, no s/s pain observed at this time.

As far as refusals, I don't work in Tele, so I can't tell you. Go with policy, ask your preceptor. If it's emergent, call the MD. Otherwise I'd wait, but again, my opinion on this means nothing.

You are a new nurse but you DO know things. Don't doubt yourself.

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i think you are over-thinking. hard not to do. forget school, and think simply. you aren't going to write those nutty nursing notes as you did in school. you want to leave "things of note" on your note. i'd gather some of your questions and sit with your preceptor to be sure on your policy for what "tabs" need to be charted on.

- if the flow sheet has "pt safety check" on there and the option to check boxes for resp even and non labored and option to check for no c/o pain, would you use the flow sheet or nurse note q1-2h? if you are doing q# rounding, you'd use the check boxes. no nurse wants to read pages of nursing notes.

- if you gave a pain medicine at 1200 and at 1245 the pt is "sleeping" do you wake them up or do you entry "pt in bed with eyes closed, resp even and nonlabored, no signs of pain observed?" --- what signs of pain are you looking for a in a sleeping person? facial grimacing? don't wake the patient. you can softly ask how they are feeling and see if they just were concentrating on handling pain (eyes closed) or sleeping. if they don't respond and you see vitals being fine as well, then you can note such.

- if pt refuses to wear ted/scd/tele, i make entry and state education offered, verbally explained, needs reinforcement, those sorts of things.. do you call the md or do you wait for rounds? what is reason for teds? when are rounds? i wouldn't get too wordy, it's not necessary. patient refused ted application, education has been reinforced but continues to refuse...

one thing, you do need to know that whatever you note that is not right, you need to have followed up on that. never just note an abnormality. remember pie (problem, intervention, evaluation)

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The nursing student inside me is over thinking.

Bstewart40, your opinion matters in such that if you encountered a problem in the past, I'd like to know your opinion on what happened and what you could have done differently. I always feel there are too many mistakes for one person, one nurse to make, I want to hear and learn from others. I understand what you mean though, our policy is to educate but of course any patient has the right to refuse any treatment and we can't force them to wear the TEDs or tele. I once heard of a confused pt who kept taking the tele off and the MD said well, we can't make the pt wear it and we can't. But the lingo of documenting I guess is where I need to be sharpened.

Netglow, for the APIE/PIE charting, thanks for bringing that up. That is something I'll keep in mind with abnormals.

Any personal experiences though, please bring forward if you feel comfortable!

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Specializes in retired LTC.

Coffee - PLEASE, PLEASE, PLEASE...use bigger font. Thank you in advance for all of us dinosaurs.

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Sorry, it didn't look like that when I was typing it up, it won't let me edit it now but I'll make make sure to adjust it in future posts! :)

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i'm a two week old new grad!

i know it's the technology age and everything, but you're the most advanced two week old i've ever seen! :lol2: sorry, couldn't resist.

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Thanks for responding. I looked at that book and a few others. Good information, I am hoping for some personal insight/experience with charting though.

I have this book and I find it to be the best reference on charting I have been able to find, and I have looked at many references. I know you are seeking personal insights and experience, but I wanted to say that I think this book may help with many of your questions. It addresses medical problems/clinical situations, professional problems, difficult patient situations and much more.

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When I was a new nurse, we charted everything we did, and were told that if 'we didn't chart it, we didn't do it'. My second job required charting by exception. I had a hard time with the transition. Your point is valid that if there is a discrepancy between two documents it might make you seem dishonest. But, worse, another nurse got pulled into court because of a hospital error. She charted by exception, so she hadn't written down her numerous checks on this patient (and by then couldn't remember because it was years later). The lawyers made it seem that she had neglected the patient.

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When I was a new nurse, we charted everything we did, and were told that if 'we didn't chart it, we didn't do it'. My second job required charting by exception. I had a hard time with the transition. Your point is valid that if there is a discrepancy between two documents it might make you seem dishonest. But, worse, another nurse got pulled into court because of a hospital error. She charted by exception, so she hadn't written down her numerous checks on this patient (and by then couldn't remember because it was years later). The lawyers made it seem that she had neglected the patient.

Just reading your post has me on edge. Im a student nurse due to graduate in a month...... WOW life just got scary

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