Charting in Hospital Research

[mksnurseRN]

I have hurt my back and been placed on light duty...so I have been given a research project but I am not finding a lot of information out on the general web, so I have a quick question for all of you hospital nurses out there. How much and how often are you required to chart at your place of employment?

For example: here we chart a head to toe assessment, plan of care, I&Os, and outcomes once per shift/ We chart drains, dressings, GI placement (NGT, PEGs etc.), vital signs, telemetry every four hours/ we chart pain, IVs/central lines, and safety every two hours. And of course A LOT of this information can be found in multiple places in each chart.

Needless to say we spend the majority of our time charting. It is preferred but not required to chart as we go...if we follow this preferred method it takes 3 hours to pass first round of medications and get all charts opened. We are thinking there has to be a better way. Please help!!

[TriciaJ, RN]

It's been awhile since I did hospital nursing. When we switched from paper charting to computer, even though it was cumbersome, the first thing I did whenever I entered a room was to open the chart and log in. I was always in there for a reason which would need to be charted, so I built it into my routine. One of the reasons for electronic records is that everything can be charted as it happens and you're not having to reconstruct after the fact.

What you're describing sounds like a lot of duplicate charting. This can increase liability because even little discrepancies can hurt your credibility in a lawsuit. You might want to focus your audit on all the charting duplications. All the information you described does need to be there, but not in multiple places. That needs to be streamlined. Good luck with the project.