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Documentation vs. Patient Care



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  #1  
Old Sep 23, 2006, 11:21 PM
Registered User
Join Date: Sep 2006
Documentation vs. Patient Care

Hi All:

I am writing a research paper for my BSN completion program regarding the amount of time spent documenting vs. the amount of time spent caring for patients. PLEASE help !!!! I am interested in the opinions of all nurses.

1. How long have you been a nurse???

2. What department or unit do currently work in???

3. Do you feel the amount of documentation that is required takes away from your patient care time???

4. How much time per shift do you spend documenting????

5. Do you use any type of computerized documentation and if so does it allow for more patient time???

Thanks !!!!!!!

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  #2  
Old Sep 24, 2006, 03:41 AM
Registered User
Join Date: Jul 2004
Re: Documentation vs. Patient Care

Originally Posted by ltg623
Hi All:

I am writing a research paper for my BSN completion program regarding the amount of time spent documenting vs. the amount of time spent caring for patients. PLEASE help !!!! I am interested in the opinions of all nurses.

1. How long have you been a nurse???

2. What department or unit do currently work in???

3. Do you feel the amount of documentation that is required takes away from your patient care time???

4. How much time per shift do you spend documenting????

5. Do you use any type of computerized documentation and if so does it allow for more patient time???

Thanks !!!!!!!
Don't know if you'll tak a response from a LPN, but here goes...
1. 10 years
2. Don't work currently (med leave) but usually sub-acute rehab/LTC
3. yes!!!
4. usually spent anywhere from 4 hours up charting or doing other paperwork....(out of 8.5 hour shift)
5. no computers where i was...all paper. don't know any LTC's in my area that use computers for regular documentation and other chart issues. everything from MAR's to MDS's are all handwritten.

hope this helps....

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  #3  
Old Sep 24, 2006, 03:52 AM
sanctuary's Avatar
Senior Member
Join Date: Mar 2005
Re: Documentation vs. Patient Care

Originally Posted by ltg623
Hi All:

I am writing a research paper for my BSN completion program regarding the amount of time spent documenting vs. the amount of time spent caring for patients. PLEASE help !!!! I am interested in the opinions of all nurses.

1. How long have you been a nurse???

2. What department or unit do currently work in???

3. Do you feel the amount of documentation that is required takes away from your patient care time???

4. How much time per shift do you spend documenting????

5. Do you use any type of computerized documentation and if so does it allow for more patient time???

Thanks !!!!!!!
1. I have been in nursing for 42 years, first 5 as a Psych Tech in Calif, rest as RN
2. Forensic psych, mental health
3. Absolutely. I sometimes wonder when I'm supposed to be with the patients, so I'll have something to chart.
4. At least 3 hours, more if there is an incident or admission.
5. No, but I have no hope that it will make much difference. It may be worse, as I can write faster than I can type.
Good luck.

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  #4  
Old Sep 24, 2006, 04:55 AM
NurseyPoo's Avatar
Night Diva
Join Date: Sep 2006
Re: Documentation vs. Patient Care

Originally Posted by ltg623
Hi All:

I am writing a research paper for my BSN completion program regarding the amount of time spent documenting vs. the amount of time spent caring for patients. PLEASE help !!!! I am interested in the opinions of all nurses.

1. How long have you been a nurse???

2. What department or unit do currently work in???

3. Do you feel the amount of documentation that is required takes away from your patient care time???

4. How much time per shift do you spend documenting????

5. Do you use any type of computerized documentation and if so does it allow for more patient time???

Thanks !!!!!!!
1. 2 years RN, 3 CNA, 7 CMA/phlebo/lab tech
2. ICU
3. At times I do feel like it takes away but I try and do it in the room.
4. The amount depends on the pt. Some days it feels like all that I do is document and others not so much.
5. Yes we do all of our documentation on the computer. Whenever possible I will do my documentation in the room. I walk in and start up the screen before I even start my assessment. This way I can document from head to toe while in the room. I also try and make a conversation about the computer while in there. The pt's who are not intubated and are A&OX3 will usually ask questions about the system. And, several are curious about the possibility of using the computer for the internet.

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  #5  
Old Sep 24, 2006, 07:41 PM
Registered User
Join Date: Apr 2006
Re: Documentation vs. Patient Care

In my opinion I don't think it's right to separate "documentation" from "patient care". Good documentation is part of patient care. I work predominantly in Recovery Room and OT. We document at the patient bedside therefore are not away from our patients thus this does not impede with patient care.

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  #6  
Old Oct 02, 2006, 09:53 AM
Registered User
Join Date: Sep 2006
Re: Documentation vs. Patient Care

1: 3 years
2: cardiac/tele/stepdown unit-quit after 2 years
3:yes
4epends on what's going on with the pt's. On a day with no incidents, I'd have to say around 3-4 hours
5:We used computer documentation and also written documentation. Lots of double charting. Thiswas required by the hospital.So, this system actually took much needed timeaway from education, personal needs, pain management,procedures, etc.
Hope this helps and good luck on your assignment.

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  #7  
Old Oct 06, 2006, 02:24 PM
Registered User
Join Date: Jun 2006
Smile Re: Documentation vs. Patient Care

Originally Posted by ltg623
Hi All:

I am writing a research paper for my BSN completion program regarding the amount of time spent documenting vs. the amount of time spent caring for patients. PLEASE help !!!! I am interested in the opinions of all nurses.

1. How long have you been a nurse???

2. What department or unit do currently work in???

3. Do you feel the amount of documentation that is required takes away from your patient care time???

4. How much time per shift do you spend documenting????

5. Do you use any type of computerized documentation and if so does it allow for more patient time???

Thanks !!!!!!!
12 years RN
LTC
yes
approx. 2 hrs (Medicare/skilled charting)
All pt records are on paper but I do use an Ipaq for my own use at work
(like wound measurements, assessments, etc. so i don't forget them before i document)

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Documentation vs. Patient Care

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