Nurse Charting Rule #1: “If you didn’t chart it, it didn’t get done.”

One of the most basic tenets of nursing is “If you didn’t chart it, it didn’t get done.” Accurate and unambiguous charting is essential for patient care, for administration, and for any subsequent patient care reviews. Clinical Coordinator Deb Bacurin reports that travel nurses are no different in this respect than permanent hospital nurses. “No matter how harried you are, you always need to make time to check your notes.” Many hospitals have transitioned to computerized charting systems, and nurses may be tempted to assume that the computer will flag any input errors. “No,” says Bacurin, “you still have to double check.” It’s too easy to select the wrong item from a drop down menu or hit the wrong key, especially when you’re in a rush.

That said, one important advantage of travel nurse jobs is their ability to introduce travelers to a wide variety of charting systems. This flexibility is a real plus in today’s job market. On occasion, hospitals will employ travel nurses while transitioning to a new patient charting system. The travel nurses hold down the fort while the permanent staff trains on the new system. These hospitals know that travelers are already familiar with a wide variety of administrative systems, and can even assist permanent staff as they come up to speed.

Bacurin advises that all nurses, travelers and permanent, should remain open to change — the only constant in healthcare. Be open-minded and view the new system as an opportunity to enhance your nursing skills set. Nurse managers report that graduate nurses, who have grown up with PDAs, mobile phones and laptops can take advantage of their comfort with technology — coaching more reluctant colleagues. And, when seasoned nurses combine their medical expertise with administrative and technical know-how, it’s an unbeatable combination.

Bacurin also advises that you keep your sense of “nurse humor”. No matter how sophisticated the nursing systems, occasional bloopers do slip through, and that’s precisely why you’ve got to re-read those notes! Perhaps you’ve seen some of these classic clunkers — widely available on the internet — or you’ve got one of your own?