Nurses notes
Hey everyone, 'just came home from a long days work. I'm curious, do any of you feel like your nurses notes lack so much info due to being so tired when you actually get to sit and write them. Today was very busy for me. With most of my patients being total care and a cna who called in I ran the hall non stop. When finally I was able to sit down and chart, I just put the bare essentials on the note. Lately it seems like I end up doing this more often. The few sentences on a paper can't reflect the physical and mental work I did throughout the day. Yet because I'm so tired and can't open a chart until it's time to clock out that's about all I can get out of myself. Can anyone relate to this?
Amen SISTER!
I do not know how many times I look back over my notes and go.......hmmmmm there was soooooooo much more than that, but dont feel as though I have the time or the effort left to add anymore.
I really hope I am not getting lazy!
clem
Hi all,
I have some general documentation questions for you hospital nurses. When in a shift do you write your notes? Do you tend to do them once, halfway through your shift, then again at the end? On busy days do you end up staying late to write and write? I have memories of that.
Do you still write notes by hand in notebook style charts? Do some hospitals have charts on computer? If so, how are you guys liking computerized notes??
As you care for your patients, do you jot down info. on a clipboard or pocket notepad? I am interested in how you help yourself jog your memories!
I am planning to do a refresher: I have been out a long time. I appreciate your up to date comments.
Crouse
Places I've been to are all charting by exception and on the computer. Sometimes there is nothing to write and others, you don't start until the next shift is here and you then have the opportunity to finally sit down. Sometimes the charting is no more than MD notifications.
I chart by exception but also always TRY to chart as I go which usually works. Sometimes it's 2 or 3 patients charts at the same time. Unless it's an emergency it's ok to say ok I'll be with you in just a minute to another patient or co-worker. I do get behind in labor when someone is pushing for 2 hours at that time I can't stop and write and have to catch up later or if a labor turns to a c-section then I have to circulate and do recovery so can't chart that last part of labor and decission making time until after recovery is done.
We have Charting by Exception at my hospital. Working PM's I do assessments at 4 and 8 pm and I chart right after. Sometimes it's hard to get to them, but most of the time I am not so busy that I have trouble charting. I used to work at a hospital where I didn't get to start charting my 3-11 stuff until 11:30, after report was done. I didn't last very long in that job because I never got home until 1:30am and it sucked.
