I remember getting ready for clinical that first day. I had my special nurse’s clipboard, a special pen with four different colors, a highlighter, and my brand new stethoscope – the one that they sold in the college bookstore in a kit with a blood pressure cuff. I printed out all the papers that my professor said we needed to bring and I already completed the pre-clinical orientation. I was all set!
What would have made things easier was if I read through the instructions on the paperwork. Nurses all over know what paperwork I am talking about: Care Plans.
I assure you, you’ve never written something like this before. This form must be hand-written (to prevent you from copy-pasting old care plan contents into new care plan contents). I sit here today, a new graduate nurse, looking at the mountain of paperwork I completed by hand over two years. In addition to Care Plans, my school also had Prep Sheets which were slightly shortened versions of Care Plans. We also had Reflections Papers where we had to compare our patient’s diagnosis and treatment with what our textbook listed. When you consider the amount of lecture work, reading, and the physical time spent in lecture, clinical and the library, the idea of adding in any extra work seemed impossible.
How do you manage all that paperwork?
Some clinical instructors will give you time during clinical to work on your paperwork. Always have in mind HIPPA. Your primary goal with paperwork is to thoroughly document a head-to-toe assessment, diagnoses, treatments, lab work and interventions. You must do so in a manner that protects the patient’s rights. If you are allowed to remove documents from the hospital, you will be required to redact (which means blacken out all identifying items including medical record numbers and patient numbers with a dark enough marker that these items are no longer visible). Some hospital policies entirely block you from removing any documents. That will mean you have to hand write all document lab values and pertinent findings.
In the beginning, you will write in your usual handwriting. Very quickly, you will write in your own kind of short-hand with very small, elementary letters (cursive just disappears when you write very small). Be careful with your short-hand and keep it to YOUR notes only. When documenting in patient charts, you must avoid unauthorized abbreviations. Most hospitals have a list of acceptable abbreviations. When in doubt, in patient charts, go with spelling everything out because these are legal documents where clarity is extremely important. However, using your own shorthand for YOUR notes is a good way to reduce the amount of actual writing. Keep your shorthand consistent to avoid confusion. You can also work together to create simplified forms. To put it simply, you have to figure out how to maximize your time and reduce the trauma to your writing hand.
How do you complete this high volume of paperwork on time in addition to all the other work?
That’s a matter of time management. Going through the rigors of finding a job, I can tell you that time management is a key skill for any nurse and one that hiring managers are expecting in a prospective employee. You have to learn to plan ahead, to anticipate when you will most likely struggle. For those who generally fly by the seat of your pants (folks like me), this will seem like a very tall mountain to climb. Having climbed that mountain, it’s actually easier than it seems but you have to apply yourself to the task.
Paperwork is usually due the next clinical shift. This might give you about 36 hours. Even if your clinical instructor forbids you from completing your paperwork during the shift, there are things you can do to help yourself later on. Looking at your paperwork, you know you’re going to be expected to provide nursing diagnoses. In most cases, you’ll need physiological, psycho-social, and teaching diagnoses. This is usually the most challenging part of the Care Plan. Start by familiarizing yourself with whatever Nursing Diagnosis textbook your school requires. Flip through it and get a feel for how it is laid out and what kinds of nursing diagnoses there are. During your clinical shift, make notes about the patient’s diagnosis and think about the aspect of this diagnosis that is most problematic for the patient. Think about their psycho-social assessment and where they might be struggling or needing help with coping. Think about deficits in their knowledge – almost all patients can benefit from medication education. Give yourself a head start with these diagnoses.
For each diagnosis, you can expect to offer three to five interventions. Many people struggle with this. Start with what you actually did and then provide the rationale for why you did it. Most often, you did more than five interventions for the patient. So, choose the interventions that directly impacted the diagnosis you listed. Some professors require your own words so be certain you ask them to explain their expectations.
Lastly, different clinical professors may have different requirements. Some may require rationales down to the cellular level, some may require more documentation than others, while some may require pressed scrubs and lab coats. Each professor will have their pros and cons. Some professors will even accept late paperwork while others will kick you out if it is incomplete. Whatever expectations your professor might have, try to learn the most from them and keep your focus on your task. The professor that required me to have rationales down to the cellular level was the reason I passed that semester. During the semester, I found the task very challenging. However, as it turned out, knowing those rationales so deeply enabled me to get a much needed “A” on the final exam. Later on, knowing those rationales helped me on the NCLEX, and in my future job interviews.
The hard work and paperwork may seem monotonous and even unnecessary at times but once you are on the other side all of it will have paid off!
Check out the two previous articles in this Nursing Clinical Series: