How to Make the Most of Your Nursing Minutes
How to Make the Most of Your Nursing Minutes
Just when you think the powers-that-be can't come up with one more category of data for you to chart, they do. Thanks to the advent of pay for performance, documentation has never been scrutinized more closely or seemed so overwhelming.
I teach time management to new graduate nurses, and one of the most successful strategies I've seen new nurses use is to document as early in the shift as possible. The first physical assessment is particularly crucial. For effective time management and accuracy, document the most time-consuming chore as early in your shift as you can. If you can document all of your first assessments within the first 2 hours of your shift, you can adapt better to any unforeseen events you'll encounter throughout the day.
Making brief notes about abnormal findings during your assessment can improve your documentation accuracy. At the end of the shift, when you're exhausted, you may have trouble accurately recalling in which lobe you heard abnormal breath sounds. Your charting will be faster and more accurate if you use your notes when you sit down to document.
If your unit has whiteboards in patient rooms, use these as documentation tools—for jotting down drugs given during a procedure, blood glucose levels, or intake and output amounts. Later, when it's time to record these facts, you won't have to waste time searching for them.
Barrier #3: Documentation
Just when you think the powers-that-be can't come up with one more category of data for you to chart, they do. Thanks to the advent of pay for performance, documentation has never been scrutinized more closely or seemed so overwhelming.
I teach time management to new graduate nurses, and one of the most successful strategies I've seen new nurses use is to document as early in the shift as possible. The first physical assessment is particularly crucial. For effective time management and accuracy, document the most time-consuming chore as early in your shift as you can. If you can document all of your first assessments within the first 2 hours of your shift, you can adapt better to any unforeseen events you'll encounter throughout the day.
Making brief notes about abnormal findings during your assessment can improve your documentation accuracy. At the end of the shift, when you're exhausted, you may have trouble accurately recalling in which lobe you heard abnormal breath sounds. Your charting will be faster and more accurate if you use your notes when you sit down to document.
If your unit has whiteboards in patient rooms, use these as documentation tools—for jotting down drugs given during a procedure, blood glucose levels, or intake and output amounts. Later, when it's time to record these facts, you won't have to waste time searching for them.
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