Wednesday, June 15, 2011

I am in Paperwork Hell

As the excitement of my first clinical rotation wears off, I am staring down the massive pile of paperwork that I need to turn in by Friday afternoon. I realized that in all the excitement of the day, I really didn’t get a thorough assessment of my patient. In fact, I didn’t get much of an assessment at all. Most of the information I did get was copied from the chart. I can probably fudge most of it for this one, since it is the first care plan we are to turn in, and it is more of a “practice” one than a strictly graded one but I am a little disappointed in myself that I didn’t get the assessment I should have.

All of this makes me realize that while I have come a long way in the self confidence department, actually talking to some people, and getting in there and doing things rather than just being a fly on the wall, I still have a ways to go before I become who I need to. The assertive, confident student nurse.

So now I will get back to this mountain of paperwork, and figure out what I need to do to make sure the next time I am in the hospital, I actually talk to and assess my patient rather than relying on the chart.


  1. When I was in nursing school our instructor sent us all back out after post conference to do a real assessment, because we had all been too shy to do it.
    One of the students did Hohman's sign (some hospitals now frown on this) and discovered a DVT. It really was a DVT. Found by a first year nursing student on her second day of clinical. It went a long way to convince us that we really could do something to help the patients.
    Susan Peterson

  2. Girl no worries, that sounds exactly like my first clinical at the hospital last semester and we were expected to turn in a 5-8 page care plan on someone we talked to approximately 30 minutes. My partner and I went up to the unit a couple days later and looked up the patient's history because she was transferred to another floor and was still active in the computer. We got a lot more info and walked away with a great grade. Hope you do well and get your work done.

  3. Teaching has LOADS of paperwork too. I didn't know about the nursing paperwork until I read this posting. Good luck with all of it and your assessments and paperwork.