 Hi guys, and welcome back to this video. Let's see. I am really really pregnant right now, so I apologize. I know I am not looking my normal video self and by the time that you guys actually see this, I will hopefully not be pregnant. But for now, I'm pre-recording videos ahead of time, which I've already mentioned to you guys. But I'm gonna do a video today talking about some tips for charting kind of just some charting stuff in general because I know that as a nursing student I was really stressed about charting as a nurse and when I precept other students they are always like concerned about charting and that's because I don't really feel like it's something that's covered a whole lot in nursing schools. So I wanted to give you guys a couple tips and just kind of run through some basic things about charting, kind of some the best things to do versus to not do. And I actually asked you guys on my Instagram what tips you had and I got a lot of the same tips. And so I'm gonna share some of those as well. A lot of these were things that I already was going to share, but I was like, okay obviously this is a very important thing that you guys took from charting and when you learn. So I'm gonna share a couple of those as well. One of the recommendations that a lot of you guys said is to chart as you go. But a lot of you also said don't forget to be a nurse first and take care of your patients first, which is very very important. We should try and chart as we go, meaning that if we do one patient assessment, like go chart that, go on to your next thing, chart that, go on to the next thing, chart that, and kind of just do things as you go in a timely matter. But there's obviously going to be times where you're really busy and you're not going to be able to chart as you go in that moment and that's okay to not be able to do that and really you have to take care of your patients first and foremost. If your patient's struggling or something's going on, you're not gonna be like, hold on, let me chart your vitals really quick. You're going to do that when it's an appropriate time. So your patients always come first, charting comes next. But in the perfect world, you should chart as you go in real time as they say. A lot of you guys recommended to write down times of things when you do them. So that way if you can't chart as you go, at least you have those times to look back onto. And I like to do this, especially when it comes to like important events or maybe I talk to a provider and I like to write down that time. So that way I know when I need to go back and chart that, especially if I'm not able to in the moment or during like an intubation or something like that. If I'm pushing meds, write down the times that those meds were pushed so that when I go back and chart them, they're at accurate times. Next tip is that when you talk to a provider or a doctor or really any ancillary staff member or family member, make sure that you're charting that. Even if it seems very simple, try to be very thorough with when you're communicating with others and making sure that's documented, especially when it comes to doctors and you're notifying them of labs, you're notifying them of changing conditions, or maybe you're just updating saying, hey, social work mentioned that the patient isn't going to discharge today. I'm just calling to let you know. Make sure that you're charting that. Even the simplest of things, just chart it so that way it doesn't come back to haunt you, so to speak, and I've never had that happen to me, but I've heard of nurses tell stories or providers that'll come back and be like, well, you never called me about that. It's like, actually, I did and you can document it. I also like to add when I've maybe called family members in there or spoke to other ancillary staff members. So like if I called a family member to get consent or maybe I called family member to update them on a patient's condition. Now, I may not be very specific in my note, but I will at least say like called patient's wife Barbara and the time is obviously in there to update on patient's condition or something like that. Now, with that being said, you really should try and limit the amount of nursing notes that you're doing, the amount of free text that you're doing because the charting systems are meant to be standardized and if you are writing notes, then you're kind of going out of the standard. So I know some people recommend to like go at the end of your shift and write a complete note on your shift. I don't recommend that and I've always been told not to do that because your charting system is there for a reason. Stick to that and don't write nursing notes unless you absolutely have to because that can be up for misinterpretation. It's obviously you can't misinterpret a checkbox, but you can misinterpret someone's writing or then you're setting yourself up to make errors, grammatical errors, things like that. My next couple tips are to maybe have a checklist at first when you're starting out charting that you go off of. Maybe you've made it yourself. Maybe it's in the charting system. That way you're not forgetting things. So like if your assessments every four hours, maybe have a little note that you've created for yourself that says, okay, every four hours assessment and you can check it off as you go. That's what I did when I first started off with a new charting system is I wrote down when specific things were due like for charting. Was it every hour? Was it every two? Was it every four? Was it once a shift? And I checked it off as I went so that way I didn't miss anything. And then I got in the habit of just knowing what to chart. But for that first little bit, the checklist was super helpful. It's also important to get into a routine with your charting. So if you chart assessments first and then you chart your ADLs and then you chart your eyes and nose and then you chart vitals, do it consistently every single time. So that way it just you get quicker at it. It becomes repetitive or becomes routine. And you will know if you miss something because it'll feel weird. It'll be off your routine, so to speak. The next thing that I like to do, and that's something that you guys recommended is to review your charting at the end of your shift or maybe at specific times during your shift, maybe after your first assessment, you review this charting or after your second assessment, you review this charting. And I like to do mine by assessment. So I start my first assessment. When I'm charting my second assessment, I have my first assessment lined up right next to it so I can see if I've accidentally clicked something that was wrong. And same thing when I'm charting anything else is I always kind of look back to what the previous thing I charted was so I can make sure that I'm consistent or if there was a change, it's documented. I can't tell you how many times I go back to look at my assessments and I've accidentally charted that this patient's right arm was flaccid and I meant to say that there was no abnormality in their arm. Like it's, I can't tell you how many times I've seen previous nurses chart things like that. And so it's important to kind of continuously review your charting whether you do it at the end of the day or with each assessment or whatever your routine is just kind of stick to it and glance over it. It really doesn't take that much time but if you can review your charting, you're gonna save yourself from making errors. So those are my tips slash your guys' tips combined together. Thanks for sharing all your tips. It was awesome to know that we're like on the same page and a lot of people agree with things and that there's kind of this like standard across the board. But if you're a nursing student and you're concerned about charting, don't worry, you're gonna get, you're gonna get it. It's just like learning a new technology today. Like you get a new cell phone, it's weird at first. Then you're like, oh, okay. It's like I've had this cell phone for 10 years. You just get used to your charting. Honestly, like, yes, there is a lot of charting in nursing, but if I sit down and tie myself and I'm not interrupted on two patients, I can chart all of my morning assessments, all of the vitals, eyes and nose, ADLs, med infusions, whatever. And there's obviously a lot of stuff to chart on for ICU patients because they have lots of lines. They've got lots of drips and things like that. I can chart on both patients and do all of that in less than 10 minutes, like hands down, less than 10 minutes. I would like to even say maybe five minutes, but that might be pushing it. But between five to 10 minutes, I could chart all that stuff. So really it's not terrible. It's just the fact that it's so much to do and you're getting interrupted constantly and if you have maybe five or six patients, then it can get a little confusing and you don't want to overlap them and make sure that you're consistent. And anyways, you guys will be fine is what I'm trying to say. So I hope you guys enjoyed those tips. If you did, give it this video a thumbs up and subscribe to my channel. And I'll see you guys next time. Bye.