Nurse Charting -- How is the paperwork?

by Josh
(Willows,CA)

Your Question:
I am in the process of heading toward my goal of RN. I just have reservations about the nurse charting and paperwork that you do. I have over 6 years experience working as a CNA in 3 different hospitals. As I worked with nurses, the main stress of their day was not patient care, but getting all the paperwork.(Nurse Charting/MARS/admissions, etc.) Many became difficult to be around while they were charting. In fact, you (the CNA's) often dreaded telling our patient's nurse that they were requesting something due to the pressure of their charting. So, to make it short and sweet. What is the ratio of nurse charting compared to actual patient care? Thank you, Josh



My Answer:

Hi Josh. Thank you so much for visiting our site. While others may have had different experiences with nurse charting, here is my take:

I started my nursing career on a floor that had only computer charting, and then later we added physician order entry on the computer too SideBar--I LOVE Physician Order Entry. I found the charting miserable and there were nights I was there an extra hour or two doing just my charting! We had 3-4 stepdown, post-op open heart or lung surgery patients on that floor.

Here is the good news though-- Nurse Charting gets much easier as you perfect your skills. Promise! I now work in a hospital that does some paper charting and some computer charting (we are transitioning to all computers) and I find I am pretty quick at either one.

I work in an ICU. I have six years experience as a nurse, and never worked as a CNA, so getting used to the hospital took me a little longer than most nurses. I have 1-2 patients per shift, but worked over five years on floors with up to 6 patients per shift.

Due to my patients being sicker now than at my previous jobs, I find I still have to chart just as much as I did on the floors because now it has to be more detailed. I probably spend about 25% of my time charting.

When I started nursing this was probably the same, but because I was slower with my actual nursing skills, that 25% came in huge chunks together and usually at the end of the shift. 25% of a 12 hour shift is 3 hours!!! So...if I didn't chart all day you can see where the problems started. And forget trying to remember what happened six hours ago...won't happen.

Now that I am more proficient, I am constantly charting little things. I chart my pain assessment AS SOON as I give pain meds. I chart how a wound looked immediately after doing wound care. Like I said, the charting is probably still taking just as much time, but I have learned to stay up on my charting like they said to do in school =)

PLEASE PLEASE PLEASE Don't let the idea of a lot of nurse charting and paperwork keep you from becoming an RN. You will learn legal shorthand. You will also learn that many nurses double chart all the time. This is un-necessary and time consuming. As with your other nursing skills, you will learn to become more proficient with time and practice.

Shannon