Tips for charting for Med/Surg nurses. Chart in real time, meaning, chart as much as you can while you are in the patient's room because you have 4 patients. For example, if you have to stay in the room while they go to the bathroom, CHART! When you are new, it is nearly impossible to remember every single detail of your assessment after the end of your first round.
Could you do a quick video on how to catch up when you're behind? Also: I am a nursing student who works as a CNA in a hospital and when I see nurses and their responsibilities... I wonder to myself, how am I going to do all of that after I graduate in May?! I know that I'm learning a lot in school, at clinicals, and at my workplace, but it just seems like a huge bridge to cross after I graduate. Can you make a video about that transition? Or maybe link the video you already made? Thank you! 😊
A paper towel is my best friend when I don't have time to chart! I jot down vitals and stuff in my pocket until I can get to a computer. If I don't have time to write anything down, I REPEAT in my head whatever I need to remember (i.e. the patients temperature or respiratory rate). Great tips Ashley!
If it is a crazy day, and you truly can’t chart as you go, make sure to write down the exact times that you did the assessment, help with ambulatory, etc. this wY when you do chart you are accurate with times.
heidi foss good tips! Some times it is impossible to chart at the exact time you do things, but writing down those times you did important things....is a must!
If I forget the time I did the actual assessment, I look back at my MAR because I most likely am passing meds during my assessment so I chart my assessment for the time I gave whichever meds I was giving at that time
I appreciate the charting tips and shared them with my fellow new nurses. Malpractice: Tidbit we found out thanks to Nurse Residency is that most malpractice lawsuits take place almost two years from the event as the plaintiff (party suing) is building up damages just right to the statute of limitations (when they can no longer sue). Then by the time it goes to court, it could be another five years. So, don’t count on memory or old brain sheet -- the chart is all that will matter.
This!! I'm only a CNA but my instructor was a RN at a nursing facility and told us a story about charting. The CNA was amazing and always charted. One day she had a patient who needed to have the rails up so she put the rails up. The patient ended up climbing over the rails and hit her head on the floor. In court the lawyer asked if the rails were up. My instructor said yes (she was on the defense stand). The lawyer pulled up the cna's chart/notebook and asked my instructor to show her where the proof was. Obviously and unfortunately she couldnt because the cna didnt document it and the facility ended up getting sued for like over a million
Amen! Amen! Amen! If I may also add a couple of things; 1) State no opinions, only facts (you eluded to that). 2) the phrases “Dr. stated ....” or “pt stated...” is helpful language when recreating the situation.
I work oncology/inpatient hospice at a hospital. No matter how hard it is, I chart in real time from the computer in the pt room. If I go to court, I want to prove that I charted while I was with the pt. It's very hard to do that because we always have 6 patients and they are all very sick. But I would rather be a little late in someone's vitamin and have all my charting done. When I get a new admit, I chart their assessment immediately. When someone comes back from a procedure, I chart their vs and a progress note immediately stating that I assessed whatever. For example, no drainage from paracentesis site, pt awake,alert,oriented, vss, bed alarm on. Etc. it's so hard to chart real time but I force myself. Now sometimes you hv another pt not doing well and you can't but almost always, I can chart in real time.
Hey Ashley, I was wondering if you could make a video on how to become faster all while not making mistakes? I am still in school but I feel like I am too slow. Thank you! Love the video
Cindy R.G. Better to be slow and have a lower chance of making a mistake than to be fast. When you are fast, you are more prone to making mistakes. Just remember to prioritize, it gets better with time.
My friend’s daughter first year nurse , only 3-4 month at this hospital and she struggle . NO LUNCH??? NO BREAKS??? Is that common in nursing???? And supervisor threaten her to let her go, because she is too slow at work, any advise PLS can you make a video for newbie like her, she would come home after her shifts and cry and cry😪😭😭😭
Has anyone done volunteering at a hospital? I have decided to pursue RN and I want to do everything that will help me gain entrance into the hospital as soon as I graduate. Its a loooong time from now but my dream is to be an RN.
As a nurse, volunteering won’t do much for you. Become a tech as you work up to becoming a nurse. That’s the best exposure I can think of that will serve you well in school and prepare you to be a fantastic nurse. You’ll learn not to leave everything up to your techs 😜 it’s a humble route to take. Us RNs can feel like we are above our techs at times. We aren’t. 🤷🏽♀️
Hoh man, charting is a huge issue for me. In my hospital we still use paper+pen progress notes so it's always a hassle if I make mistakes/need to change something etc. I hate it so much! Usually it's difficult to find charts particularly when rounds happen and when you do get a hold of them I often have to rush through charting my notes! D:
