 Hi guys and welcome back to my video I am having a lazy day so I'm not wearing any makeup and I'm sorry that you have to look at my face like this oh my god my hair um anyways I have been off like five days and I work the next three so I'm like you know what screw it I'm not getting ready for this video because I want to have a relaxing day on my last day prior to working anyways I want to do a video today on tips for charting for nurses or just anyone in general that has to chart I guess um but funny story back when I was in nursing school I was like so excited to chart I remember my clinicals I finally was at a clinical location that let nursing students chart and I was like all over it and I remember the nurse was like you know you know like sort out a little bit because you're like not gonna like charting and to be honest I don't really mind charting other than the fact that it's like just another thing to do to check off your list and um you just you have to do it it's a part of the nursing world and charting always changes and things that they require and don't require and all that um so I want to go through kind of some tips for charting not necessarily like I don't know I don't say how to chart because I guess these are some tips on how to chart but anyways let's just jump into this video and I'm gonna stop rambling now but my number one tip for charting is to chart as you go and in real time if it is possible there's obviously several situations and incidences where you're just too freaking busy and you don't get a chart till the end of your shift it just happens some days are like that um but make sure you're charting if you can as you go I personally like to go in assess one patient get them all situated past their morning meds come out chart everything go assess my other patient come back out chart everything you want to make sure that you are timing things accurately for when you actually did them so I see a lot of nurses that put in their charting system or like in the chart that they assessed both their patients at 8 a.m but realistically you were not in both rooms at 8 a.m assessing them and god forbid you ever get pulled into court which luckily I have never had to do that but again it really matters like two and a half years so that's not very long um you want to be able to prove that your times are consistent and accurate with the events that are going on and if they pull up like oh well you're working that day you had these two patients and they see that oh you were also in this room at the exact same time how do we know which room you actually were in you just don't want to put yourself in that situation even if it's like I charted one assessment at 755 and the next one at 8 a.m good different times and I do that for all of my charting my charting for my like IVs and like medication infusions all those different things I try to be very consistent my next tip for charting and this is the biggest tip I give nursing students is chart every single encounter or conversation that you have with a provider it's so easy to be like oh that wasn't that important and just like blow it off and don't chart it but I guarantee in your charting system there's somewhere that you can put like uh spoke with doctor so-and-so notified of blah blah blah and then you can click like orders received no orders received whatever it may be everyone's charting system is obviously different but even if it's so simple as like you went up to a doctor said hey do you want me to put in a feeding tube it's like day three maybe we should start feeding the patient and the doctor says nope not right now let's give it another day and you chart that in your charting system and let's say the next day the doctor comes back and says well why didn't you put enough feeding tube well you could be like well you told me not to yesterday and very rarely are you actually gonna like pull up your chart and be like well doctor look at what I charted yesterday on you um but you just need to be very state the facts non-biased what the conversation was what the result was of it don't let your emotions get into involve which I know sometimes it's hard if a doctor is yelling at you and then just like refuses to give you any orders still chart empty notified of blah blah blah no orders received and your bases are covered because if you have to go to court again you just want to make sure your bases are covered and I know it sounds silly to like be like you're charting like I mean it's a legal document like you're charting you're to save your butt and I know it sounds kind of silly and like stressful but like that just is what it is you're trying to save your butt if something were to happen and there's a lawsuit you need to be able to you're not going to have chances on this is an extreme case you're not going to remember that exact patient scenario again it's an extreme case but you're going to remember how you charted and be able to go through and support your evidence my other tip for charting and not everyone does this is I go throughout the end of my shift and I review all my charting even if it's just a quick little scroll through to confirm that I didn't chart that you know their left arm was flaccid at 8 a.m. but at right or but at I can't speak that their left arm was flaccid at 8 a.m. but then at 12 p.m. they had equal griffs in all extremities unless that was actually true but you know I caught myself many times on like flaccid or like their pupils accidentally charted you know that one was sluggish and one was brisk and if it's true that's true but like those are big differences and potentially the difference between you're having a stroke or you're not and you just need to be careful so I review all my charting at the end of each shift I think though I'm going to just end the video there I could talk about charting all day but if you have any other great tips leave them down below I hope you enjoy this video give a thumbs up and subscribe to my channel and I'll see you guys next time bye