In this video, nursing educator Christina Rafano shares a personal story about nearly being written up during clinical for failing to chart, using the anecdote to illustrate how easy documentation gaps can occur even on a seemingly perfect day. She then provides concrete, actionable tips for nursing students to avoid similar mistakes: (1) document while in the patient’s room or immediately after leaving, using bedside computers or a “brain sheet” for interim notes; (2) avoid all unapproved abbreviations and acronyms, writing everything out to prevent misinterpretation and legal risk; (3) always assess and document patient responses to each medication, noting vital signs, urine output, edema, and timing of drug effects, because “if you didn’t document it, you didn’t do it.” She emphasizes the legal ramifications of missing documentation and stresses that thorough charting protects both patient safety and the nurse’s liability. The video also promotes her nursing SOS membership, which includes a fundamentals course with detailed charting examples and SBAR reports, and offers a free study checklist. Throughout, she maintains an encouraging, supportive tone, acknowledges viewer comments, and urges viewers to like, comment, subscribe, and share the content.
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In this video, I'm gonna tell you the biggest things you must do as you're charting and documenting at clinical. I'm also gonna tell you a super embarrassing story about how I almost got written up during nursing school. So if you're feeling like a failure, like you just can't do it anymore, trust me, you are not alone. Listen to this story. It'll make you feel better. Now hit that subscribe button and click the notification bell and let's dive. Dive in. Oh, boyfriend. You know those moments you have in nursing school where you feel this small or even smaller? Well, this was one of mine. I was always pretty good at clinical. It honestly wasn't my favorite thing in the world, but I was still pretty good at it, or at least I thought I was. So I was working with a CO nurse, and it was in the point of my program where I had a lot more autonomy. I was able to do a lot more by my myself, and I had a full patient load just under the supervision of a nurse. So I think it was like three or four patients that I had that day. So I did everything and totally rocked it. Seriously. I remember that day like it was yesterday. It was one of those clinical days when somehow everything just goes super smooth. All your patients like you and you feel like a rock star. That is how I felt until I got to pre conference the next morning. So pre conference is where our whole clinical group met up before clinical to go over things and what we're going to do. And when I walked in, I noticed that my instructor had a few small slips of paper in her hands. And then during the whole pre conference, she went over patient safety and documentation and how important it all is and was super clear that one of us had dropped the ball. And I bet you can guess who that was. So after pre conference, she hands me these slips of paper, and it's notes from my Kohners from the day before with a list of all the things I had forgot to do. And pretty much all of it was charting. Like, did I seriously forget to chart? Like, I could not even believe it. There were a ton of things on this list that I had forgot to do. So my instructor and I went back through the patient chart, and sure enough, there were gaps everywhere. I was like, are you kidding me, Christina? How in the world did you have such a great day and forget to chart about it? So my instructor was not happy, the CO nurse was not happy, and the nurse manager was obviously not happy. I had managed to make a whole lot of people Upset and worried all in the matter of hours. So as you can imagine, it wasn't super fun to go back on the floor knowing all those untrusting eyes were on me. And yes, my instructor did go over my charting more closely after that, so that was all super embarrassing. Thankfully, thankfully, I did have my brain sheet with me from the day before, so I was able to go back and document the things that I had written down, which thankfully was quite a bit, but it was still very embarrassing experience to have. So if you feel like a total loser at clinical or in nursing school right now, join the club. It happens to all of us. And you know that charting is a huge deal, right? You have to document everything, everything you do. So I want to walk you through my best tips to help you do it right and not make the same mistake I did. And if you are a nursing SOS member, we have a whole video training for you on best practices for documentation and how to do it right. We've also got examples of charting and SBAR reports in there for you too. It's all inside the fundamentals course in your membership dashboard, so be sure to check that out after you watch this video. So the first tip I have for you is to document while you're in the patient's room or right after you leave. If your clinical site has computers in all the rooms, use them and document while you're in there. It's just faster and safer that way. If not, make sure that you're using your brain sheet and writing things down while you're in the room and then document immediately or shortly thereafter. Whatever you do, do not leave all of your charting and documentation until the end of your clin day. You will not remember everything you did throughout the day and you will forget stuff. So that is a very dangerous thing to do. So please, please, please make sure that you're documenting as you go throughout your day. Do not wait until the end of your clinical day. Now, the next tip I have for you may end up being a big legal issue, so I highly recommend that you follow this one and that is to write everything out. Don't use abbreviations or acronyms. There is a whole list of abbreviations that are not approved by the Joint Commission and you cannot use those abbreviations in your charting. When I was in nursing school, I would see other students use this one. Bl, C, L, W, R. Like, what does that even mean? They meant to say bed lowered, call light within reach. But if I'm asking what it means, what do you think an Attorney is going to say, this is not an approved acronym, my friend. Honestly, I would just say stay away from abbreviations and acronyms. If at all possible, just write everything out. It's the most clear thing to do and there won't be any question about what you meant. Now, the less ambiguous and open for interpretation your charting is, the better. Now the next tip I have for you, I hardly ever see nursing students doing, and it's a big, big mistake to forget about it. You absolutely must chart this, and we'll talk about that in just a minute. But before we dive into that, I want to give a shout to Zella for our YouTube comment of the week, which says, the ending of your video literally just made me cry. I don't have any supportive people behind me, so to hear this really, really just motivated me. I needed to really hear it. Thank you for calling me out on my stuff. I needed to hear it. Aw. Thank you so much for your sweet comment, Zella. I am totally supportive of you and you are going to be a rock star in nursing school. Keep your comments coming, friend. I love getting all of your sweet comments. Also, tell YouTube that our videos are helpful and that more nursing students should see them. So one of the best ways to support our channel is to comment on our videos. I really, really appreciate it. And of course we read and respond to everyone. So thank you for your support, friend. Now, the next tip is super important, and I hardly ever saw nursing students checking or documenting this during clinical bad news. You really need to be doing this, and that is assessing and documenting patient responses to medications. So what does that mean? That means if you give a blood pressure medication, you recheck their blood pressure an hour or two after you gave that medication. If you give them a diuretic to decrease their edema, you assess their urine output and their edema throughout the day after giving it. Each medication will work at a different rate, so you should know when it peaks so that you can know when to reassess the patient and document it. Because here's the thing, friend, you're giving a lot of medications throughout the day. That's a lot of opportunity for something to go wrong. You always need to be assessing your patient and documenting that you assessed them. How do you know that a medication worked if you don't reassess them? And how do you know if they had a reaction to it if you don't reassess them? You need to make sure that that you're always documenting the patient's response to their medications. There is one main principle you need to always follow, and that is if you didn't document it, you didn't do it. So if you didn't document how the patient responded to a medication, that means you never assessed it. And if you never assessed it, that opens you up to major legal trouble. So make sure you're documenting everything you do at Clinical in the next video we are going to talk about how to go to nursing school and still feel like a good mom. So if you're a mama and you're having some mommy guilt about not spending as much time with your kiddos as you'd like, then this video is for you. So make sure to hit the bell so you get notified when that video goes up. And if you want a step by step guide on how to study in nursing school, I have a free nursing school study checklist for you. We will put the link in the description below for you to download that. Now make sure to like comment, subscribe and share this video with a friend. And click on one of these videos right over here so you can keep rocking nursing school and go become the nurse that God created only you to be now. We'll catch you in the next video my friend. Take care. Bye bye.
