Many nurses do not chart? - page 4

Hey, I was just wondering. On my unit I leave late every shift because of charting. The other nurses always leave on time, and they leave A LOT of charting blank. I am realizing that if I want to... Read More

  1. by   NurseBlaq
    Quote from Lil Nel
    You are right, nursing school teaches nothing about charting. And I am recent graduate (May, 2016).

    We spent time learning how to do hospital corners (with sheets), even though hospitals use fitted sheets, but no time on charting!
    One of my professors was also an attorney who specialized in medical malpractice. She told us to "chart like you're going to court" so I do. Things others may think is excessive may save your career one day. You won't remember what you did for XYZ patient 6 years from now if something came up. Add to the fact people are sue happy and nurses are the lowest on the totem pole to catch blame cause facilities protect doctors and supportive staff don't have a license to lose and haven't struggled through nursing boot camp. I trust nothing and leave out nothing. I've worked with enough snakes, especially wicked NMs, to leave anything to chance. Chart as you see fit cause it's your license!

    OK off my soap box, ugh. LOL

    Having said all that, be cautious not to chart personal opinions or anything that will get you dinged later. There is a such thing as too much detail in medicine. Maybe try getting with your facility's education dept. and ask for their input or some tips.
  2. by   Tele RN 92
    Quote from NurseBlaq
    One of my professors was also an attorney who specialized in medical malpractice. She told us to "chart like you're going to court" so I do. Things others may think is excessive may save your career one day. You won't remember what you did for XYZ patient 6 years from now if something came up..
    100% agreed. How high are the chances of going to court/losing license/getting sued? I'm scared and confused. I wish we learned more in school 😭
  3. by   NurseBlaq
    Not high unless something major happened or there's a family member who just won't let go. Her rationale was if an attorney or medical expert can read your notes and get a picture of what you did for that patient then they won't need to contact you. She said the worse thing for a nurse is to be in a courtroom and have your notes up for all to see and you can't explain it. Cause you know the saying "if you didn't chart it, it wasn't done." She said you can't explain it later cause you didn't document it. She also said you're more likely to not remember cause look how many patients you will have taken care of over the years. The only patients most of us remember are our favs, our less than favs, and those who said something that made us laugh & remember them.
  4. by   Tele RN 92
    Quote from NurseBlaq
    Not high unless something major happened or there's a family member who just won't let go. Her rationale was if an attorney or medical expert can read your notes and get a picture of what you did for that patient then they won't need to contact you. She said the worse thing for a nurse is to be in a courtroom and have your notes up for all to see and you can't explain it. Cause you know the saying "if you didn't chart it, it wasn't done." She said ..
    Thank you! That helps a lot
  5. by   jodispamodi
    What type of charting are doing?, an admission assessment or a focused assessment? Are you writing comments after each entry? Are you writing a lot of notes? Are you charting throughout your shift or do you do it all at the end?
    Honestly, I doubt other nurses are leaving charting undone, esp. if you work in acute care- auditors and risk management would have been on their backs about it by now. I once worked with a nurse who appeared to be charting all night long, then when report came she would grab a cow, bring it to report, then continue charting after report was over, there was nothing that happened on our shift that required that much charting, so I now wonder if she was just trying to get some OT as she was per diem, anyway I digress.
    Take a look at what you are charting, if you have a patient who came in with a broken leg, you should focus your charting around the broken leg, and if his ls, bs, and etc are within normal limits, you should just chart wnl. If something is off, you hart that as well. Are charting on the care plan? Are you getting overly wordy on that. I know management likes to have a beautiful narrative in there for cms, but honestly for me, for the patients chief problem I will write one sentence, then the rest I usually just document progressing, no change, etc. If they would like me to chart a beautiful narrative, they need to give me less than 5 patients. As far as notes, if the patient condition changes, and the team needs to be notified I write a note to cya, if the patient condition changes, say had rhonchi but cleared after IS use I document that in the assessment. I also try to batch my charting. So if I go in the room to gives meds, ask the patient his name, dob, how his pain is, listen to his lungs, and bowels, I can chart on all that while I'm still in the room. (and if I need to page the team I document that as I'm paging them,) and for the rest of my charting I try to do it in between med passes, dressing changes etc. On the days when I've been insanely busy and unable to chart much, I start charting before giving report, and while I'm waiting for the next nurse to come, rarely do I stay late because of charting. I
    If you have friendly coworkers, you can always just ask them if they can give you any pointers for timely charting. Although again, I suspect they are doing focused assessment/charting.
    Good luck.
  6. by   sunny time
    I've seen some pretty good chart as a chart review nurse. so good in fact, that it makes me wonder if all the things that were charted were actually done. nobody has that much time in an 8 or 12 hour shift. especially, if there is a glitch in the day.
  7. by   OnOn2NICU
    Quote from Tele RN 92
    I think I am realizing that we learned nothing about court/defensive charting/ the legal system in my nursing school. I used to just chart what I thought was relevant. As the years go by, I have gotten dinged for things/managers keep adding small random things we "have to chart". Makes me wonder have I been doing this wrong all along? Why do they make a big deal out of this.. aren't focused charted assessments more important? (Frustrated)
    Nope. But CMS has changed the way they reimburse. That's why there are things that must be charted (like turns, pressure ulcers present on arrival os, etc)
  8. by   Reyn04
    Perhaps its a time management issue?

    I chart regularly throughout my shift & rarely leave late & have never been "dinged" for charting through 5 hospitals both paper AND electronic. I do a final chart check 30-45 mins before incoming shift (time permitting, but always before I leave). I've worked ICU (2:1), PCU (3 or 4:1), Med/Surg (5 or 6:1), Procedural (4max :1) at times with being Charge or a clinical teacher to 2 & checking their charting. What I'm saying is I've experienced a lot of different scenerios & census ratios. I stay late on rare occasions but as a rule am out on time.

    If you're staying late nearly every day, something you're doing or not doing is not working. Find someone whose charting is complete & appropriate & who leaves on time & maybe get a tutorial? Or talk to staff ed/ informatics for a charting review and or streamlining discussion.
  9. by   NurseNinja1990
    I just learned some keyboard shortcuts that really cut down on my charting time. That, and videogames have made me a fast typer lol

    Some examples: TAB to go to the next section, and SPACE to select the first option. Alternate SPACE and TAB and you can fly through the chart under the sections where you found no abnormal assessments.
  10. by   sunny time
    yes that is true but then I saw there was a miracle on our floor because a quadriplegic walked in his room for 1 CNA and the nurse confirmed it with her charting. but by the next shift alas, he was a quadriplegic again. this is very had to explain to the State during survey. also looks bad for the nurse and cna
  11. by   HelloWish
    When I worked the floor, I charted at the bedside 90% of the time. I was a new nurse and left on time most of the time, I can think of 3 times I didn't. Older, more experienced nurses didn't chart until the end of their shift and left late every time. I think charting at the bedside when possible helped. I charted what needed to be charted.

    Also I could copy the previous charting. I would also check it over and change appropriately, because their were times when an amputee had a pulse in a non existent appendage. But copying and pasting saved time!
  12. by   Accolay
    Quote from NurseBlaq
    One of my professors was also an attorney who specialized in medical malpractice. She told us to "chart like you're going to court" so I do.
    I think if you amend it to this: "chart like you're going to court.... for serious patient problems concerning life and limb."
    "I know they can't breathe... I'm charting it right now!"
    If I'm going to get sued because I did not emergently get Tylenol for a headache or a cough drop for a sore throat, then so be it. But I have confidence that it wont happen. (Now...if you ignore your patients pain for a whole shift, that's a different story...) I will also amend amended quote to include charting on patients or families with behavioral problems much more frequently and quote them in my charting.

    Now consider the scenario that your patient has been declining all day, the MD doesn't make it a priority, and the patient eventually codes. Certainly now is the time to chart like you're going to court. State who you called, who you talked to, how you escalated the situation and whatever else you did.

    But charting every single detail on your patients ad nauseam may not make you a better nurse and serve to make you stay late. For the love of Pete, some still chart on patients tattoos or old scars. What a waste of time.

    Chart by exception. Copy forward only your own charting. Don't chart things twice. Notice things that are not WDL. Advocate for what is really important, right now. Guaranteed, you will at some point have to choose between patient care, or charting what you did.
  13. by   maxthecat
    How do you reconcile "charting by exception" with "if it wasn't charted, it wasn't done."

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