Nursing educator Christina Rafano shares three charting tips for clinical students: use only facility-approved abbreviations to avoid legal problems, follow a head-to-toe pattern with brain sheets to capture data in real time, and document interventions immediately rather than at shift's end, as delayed charting can cause fatal errors like insulin mix-ups.
I had to record this video because so many nursing students are doing it wrong and you might be one of them. What is up, my friend Christina here with nursingschoolofsuccess.com and today's video is all about nursing documentation, tips and things you should and should not do when it comes to patient charting during nursing school. But before we get started, make sure that you're subscribed. Subscribe to this channel and click that little bell icon so you don't miss out on a future video that we post here. So the first and arguably the most important nursing documentation tip I have for you today is to only use approved abbreviations or acronyms. But here's the kicker. There is no standard for acronyms and abbreviations in nursing. It is different facility to facility. So you must check with your clinical facility and get their approved list of abbreviations and acronyms before or you use them. Friend, I am super serious with this one. There are times when I get up on my soapbox and preach to you, and this is one of those topics that just lights my fire. Proper documentation can either make or break your nursing career. So let's take an example. Here's an abbreviation that I've seen nursing students write before. BL C L W R What? Okay, so maybe you know what this means and maybe you don't. And that's exactly my point. Because what happens when your documentation is subpoenaed by a court and now you need to defend your nursing documentation in front of a judge? If that abbreviation isn't stated as approved by your clinical facility, it is now up for interpretation. And girlfriend, you can bet dollars to donuts that that lawyer is going to shred holes in it faster than you can catch your breath. So, my friend, save yourself and write out your words. If it's not an approved facility abbreviation or acron? Yes, it takes more time. Yes, it's a pain to do, but it's a small price to pay for knowing that your documentation is ironclad. So if you're with me on this and you're just thinking, heck yes, Christina just saved my life, write love in the comments below. I want to hear from you. So that is tip number one. Only use approved abbreviations or acronyms in your nursing documentation. And on that note, I do have a free cheat sheet of possible nursing abbreviations and acronyms for you to download. That link is down below. But beware, do not use them unless they are approved by your clinical facility. They're just meant for you as a reference. If you see Someone else writing them, you'll know what they mean. But I do not recommend using them during your nursing school clinicals if they are not approved by your clinical facility. Okay? Now tip number two is to follow a pattern with your documentation. Now there's a reason in nursing we call it the head to toe assessment, because we literally go from head to toe is how. I recommend that you write out your documentation too. From head to toe. So when you follow the same documentation pattern as you do when you're assessing your patient, it's less likely that you're going to forget something. So each time you document follow the same pattern. Think back to your nursing assessment. And better yet, as you're doing your nursing assessment, write things down on your brain sheet. If you can't document as you go. Nursing brain sheets are those little half sheets or full sheets of PA with all those boxes and lab value skeletons and all that jazz. They're pretty cool. So if you're not sure what I'm talking about, that's totally cool. Next time you're at clinical, ask your nurse or your instructor for an example brain sheet so you can see one. They will help you out a ton. And good news, a lot of those brain sheets actually do follow that head to toe format. So they do walk you through that head to toe assessment in some way, shape or form. So when you're assessed, so write your assessment data on your brain sheet, you'll be able to to it as you document in the computer or paper chart later. So this will also help you remember everything. So that is tip number two, follow a pattern with your documentation so you don't forget anything. You can literally go head to toe. And finally, tip number three is to document right away. Don't wait to document on all your patients until the end of your clinical day. Document as you go. First of all, too much happens during clinical for you to remember everything that you did. So if you wait too long, you will for at some things even if you tried to write it all down in your brain sheet. Now, second of all, the healthcare team will need to know what's going on with your patient in real time. So you really need to document as you go to keep them in the loop. So here's an example of how this can go very, very wrong. So let's say that you're working with a preceptor or a co nurse on the floor and you have a patient whose insulin is due before breakfast. You grab their tray and give them their insulin like a rock star nursing student. But you forget to document that you gave it. And let's say that your CO nurse comes in, sees them eating, checks their chart and sees that you never gave their insulin because you didn't document it. So she gives it again. Huge deal. Friend. This mistake has huge consequences not only for the patient because they could literally die, but also for your nursing career. So always, always, always document right away everything that you do. And so friend, those are my three major T tips for proper nursing documentation. Tip number one, only use approved abbreviations or acronyms that are approved by your clinical facility. Now tip number two, follow a pattern with your documentation so you always document the same way every time you don't forget stuff. And tip number three is to document right away as you go. Now, if you found these tips super helpful, write love in the comments below to let me know. And of course, make sure that you're subscribed. Subscribe to this channel and click on that little bell icon to get notified when we post a new video. Thank you so much for watching, friend. Now go become the nurse that God created only you to be. And I will catch you right here next time on the Nursing School Show. Take care of.
