I. Hate. Charting.

That's pretty standard charting. You get used to it and it gets faster. The IV checks are scheduled at the most random times but they are meant to be Qshift checks (at least they are as a standard). So you make sure you bring flushes with you and when you're doing your shift assessment you flush the IV. Are you using Epic? If so, the"brain" shows IV checks but as long as you charted one per shift you can click skip on it. It's just reminding you it needs to be done. I also know that some of my patients the brain has vital checks too often as they are auto populated by different things. Know what your patient truly needs for vital checks and just click skip on the rest (I go through and do this at the start of my shift so I only see what's "real"on my brain).

If you're working nights, care should be more tightly clustered than on day shift because patients need sleep. Patients have meds at 7,8&9? They're getting all of them at 8 at the same time I'm doing their shift assessment, IV flush, etc. Patient has a random med scheduled for 2am? Send a note to pharmacy to see if it can be more efficiently clustered with 2100meds or 0600 meds, etc.

I'm an outlier because I love charting, but honestly as you get more experience the charting gets easier and you get more efficient at clustering your checks. Also I usually chart in blocks of time, so I make notes of things that are outside of WNL and then when I sit down to chart (and eat my dinner) I can bang through the charting. You don't need to chart that safety check exactly as you did it if it was WNL, make a note of the time and then chart it later (add column with time assessment was done) with the rest of your stuff. I only chart in real time if I have to act on the assessment (have to call the doc, have to give prn, have to change an order etc).

/r/nursing Thread