My coworkers are always joking with me that I chart too much. It doesn't take up more time, I just chart everything I do. I have several jobs and at one job, for instance, I have two high acuity patients. Every time I do something with my patient I chart it. It is paper charting and I write very small. I can easily have a page and a half for each patient. A few of my coworkers may wait until the end of their shift to chart on everything. Some do as I do. After I preform a procedure, I chart.
Co-workers also joke with me at my other job. It's computer charting and I chart a summary after each patient. They will jokingly say, "I want that book signed when your finished."
Okay, here is my concern. Whilst in nursing school
my instructor told me not to chart so much, that I could legally get in trouble should anything happen. I also know from common sense that "if it isn't charted it isn't done". I just chart the facts, nothing else. I chart what state the patient was in before I preform a procedure, what procedure I did...per orders, and what the outcome of the procedure was. I chart every hour on a patient sometimes when it is only required to chart every 2 hours but I just chart every time something is done....etc.
Dec 17, '12
If more than one person is telling you the same thing, then you need to look at it more carefully. If you are putting in extraneous information then that might come back and bite you some day. Just chart the facts. Also, could it be you are charting to keep from actually doing something else? I worked with a nurse who wrote a tome on each patient, but was too busy charting to really get her work done or help the rest of us with other tasks. She "hid out" on the computer.
Last edit by classicdame on Dec 17, '12
: Reason: spelling error