Does anyone really read all this charting?

[gypsierose]

So I know I have to do it, and I know it gets crunched through a spreadsheet somewhere and some bean counter bills for it, but does anyone anywhere read all this charting I do? These hours of drop down menus that pull me away from my patients? Disclosure- new nurse.

[caliotter3]

I usually start my shift by reading previous charting after I have done the assessment. I typically find that 9 times out of 10, something important, or not so important, but still pertinent, has not been passed on in report and I catch it by reading the charting.

[ruby_jane, BSN, RN]

At my old job we had episodic chart audits (as in, a team would come in and do these). We charted longhand back then and I was told that the detail I put in "really told the story" especially in the unusual cases.

Now I chart to cover my assets. And every time I get tired I try to picture my words up on a projector screen where I'm having to defend my license. Paranoid? Maybe. Worth it? I think so.

[Ambersmom, BSN, RN]

at my former employer, risk management and patient safety audited charts regularly, it often seemed so they could pull you aside and question you on why a patient had a foley, where I&O's for a certain time or meal were, why the patient had 3 pillows instead of 2...

There were way too many hands in the cookie jar, it created defensive attitudes and nursing.

[nyashan]

I dont think anyone really reads nurse charting...they only really read if 'somerhing ' happens. Ie an unsavory pr outcome. So one charts as is there is an unsavory outcomw...all the time. 8

[SouthpawRN]

The double and triple charting is frustrating and can also create liability. if you say something in a progress note but didn't click the right box in one or two other places on the spreadsheet, EMR then that is a discrepancy that the lawyers will pounce on.

[bgxyrnf, MSN, RN]

The double and triple charting is frustrating and can also create liability. if you say something in a progress note but didn't click the right box in one or two other places on the spreadsheet, EMR then that is a discrepancy that the lawyers will pounce on.

That's precisely my issue with clicking flowsheets... it's much too easy to inadvertently click the wrong selection without realizing it but even with the occasional typo, my intent is crystal clear in my narrative.

Were I sitting on a jury and the case hinged on an exculpatory selection from a large flowsheet, I'd have to weigh that against the possibility that it was inaccurately or inappropriately selected from the various choices. However, if the exculpatory claim was written (typed), I'd only have to weigh the truthfulness of the writer which, barring evidence to the contrary, I'd have to grant as a given.

I consider a narrative to be a much more reliable information source than I do a flowsheet.

[HalfBoiled, BSN, RN]

If your pt is very stable, then probably not.

If you have a critical patient, then yes.

[Flatline, BSN, RN]

My wife who works for an insurance company reads every word of those charts and spends much of her time calling facilities asking why they did or did not chart this thing or that thing.

[3ringnursing, BSN]

I read Master IM notes, and other people's charting all the time.

Yes, I need to get a life ...

[gypsierose]

Yes I definitely do read notes, but not the drop down box charting so much. If I read it before I do my assessment, I feel like it narrows my focus a bit, maybe?