Consolidating Nursing Paperwork & Charting
- 0Feb 26, '00 by MarkRNI work on a cardiac stepdown unit where there seems to be an increasing amount of paperwork that we are expected to keep up with. In this age of nursing shortages and having to "do more with less", we are bogged down with increased documentation. We have a mediocre assessment flowsheet which entails a fair amount of writing in the nurses notes to further explain irregular findings. We also have numerous other sheets that are kept in folders near the patients' rooms: IV assessment flowsheets, care plans, pain assessment flowsheets, I&O sheets, etc. I am on the clinical policies improvement committee and we are trying to find ways to consolidate this amount of paperwork as well as avoiding double-charting of information. For example, when we D/C or change IV sites, we are expected to document all of this on the IV flowsheet and our nurses notes/flowsheet; when a patient has pain, we are to document this on our pain assessment sheet and on our nurses notes/flowsheet. Do your hospitals/floors have this amount of paperwork to complete? Do you have the same problems of double-charting? If not, please give some suggestions on ways to improve this. I would love to design a better flowsheet and find a way to have the care plans, I&O's, IV & pain assessment sheets become a part of this flowsheet. Maybe some of you have excellent flowsheets like this - I would love to hear from you! Thanks!
- 0Feb 29, '00 by ecbSorry, never seen a GREAT flowsheet, but I have made spread sheets to be used as report sheets that are very helpful to float personel, and agency nurses, in my NH we have to document pain and relief in MAR, Narc book, and chart, unless we ALSO have to put it on the 24 hour report sheet, then we have to explain the whole change in condition in the note.
IVs are on the room to room I&O the I&O book, the MAR, and the IV record sheet, as well as the chart, unless we have to document a site change, then its on the 24 also, usually with an incident for why it needed to be changed (unless it was actualy scheduled to be changed then which rarely occurs in the elderly)
AND don't even got me started on drs apointments, transfers, or 911 outs
I agree there has GOT to be a better way, I find that more places to document gets us (LTC, not hospitals) in BIG trouble with the state inspectors, because if there is ANY discrepancy it is false documentation, and god forbid you leave a BLANK
*** May we all have the serenity to accept what we cannot change, and the determination to change what we cannot accept. ***