The first thing I would say about today was thought provoking. What I mean by that is it appears that everyone has different organizational skills. Plus not everyone thinks at the same speed or reacts in the same way. Anyways, I noticed throughout today that I was sometimes one step ahead of my nurse. I was even able to help him find different areas of the charting when he got confused, where something in particular was in the charting. The other thing I noticed was they have an electronic charting system, but still have a lot of loose paper. Then when I was looking at the files, it appeared to be unorganized. The main thing that went right today was continuing to stay positive and ask questions. Another thing I was able to ask was about the floors again and ended up with some more information on them. The 2 West area …show more content…
I was able to understand how they documented the medications and the encounters. It was interesting because there documentation system is new; they have only had it implemented for the last three almost four weeks. As I was learning some tricks about the system, the nurse was learning with me. I was able to fulfill my SMART goal regarding the difference between documentation in the hospital setting and the SCCF. The biggest different is the nurses are not constantly checking on the inmates, and when they do that is when they fill out an encounter. The encounter will describe any injuries and what had occurred. Another part of the documentation is scheduling appointments for when the doctor is on sight. They will only have the doctor on sight for one day a week, but at one the doctor was unable to see any of the inmates for an entire month. The other SMART goal I was able to start on, was knowing the top 25 medications given; I started recording some of the medications as my nurse was drawing them up. I wrote down the ones that continued to come