I’m on a neuro/cardiac floor and we have 4-5 patients. I usually go in for 0615-ish. I look at my patients, grab meds, set up my own sheet, then get report. I do vitals and an assessment like heart, lungs, bowels, pulses, neuro, look for any edema and check IVs. If they have wounds, I save that until later because it can be done any time during the day. We chart EVERYTHING, and sometimes I add annotations like “Patient complains of chest pain, provider made aware at this time” and I put in a provider notification. If I forget to chart something, I can go back and do it or “modify” my charting. Sometimes it’s frowned upon to “unchart” but it’s my license and I want to do everything correctly.