Nursing and The Art of Arboricide

**VivaLasViejas**, ASN, RN

Yes, that really is a word.

I know because I was looking for a term to describe the mass murder of trees, which supply healthcare providers with the gazillion reams of paper we handle every day in order to prove that we've documented the proof that we've provided documented care to our patients.

If that sentence is a trifle confusing, read on........you'll know exactly what I mean before long.

And to think I used to complain about the charting I had to do as a floor nurse. "I went to school to take care of patients," I was fond of saying---not to chart the suppository I'd just given on four different pieces of paper. I didn't know what paperwork was until I became a DON, and by then, of course, it was too late to start wondering if more paper really translates into better patient care. I still don't know for sure; I'm too busy moving recycled wood pulp around to actually PROVIDE any patient care.

Take, for example, the falls management program at my place of employment. Back in the old days---meaning before July---we merely filled out an incident report, charted the investigation and interventions on the back of the IR, and made a note in the resident's chart. Then disaster struck and one of our facilities had a bad survey, so Corporate has been cranking out new pieces of documentation on almost a daily basis ever since.....its crowning achievement and signature legislation being a six-page fall report. Six pages. It's enough to make a government bureaucrat weep.

Actually, it's SEVEN pages, if you count all the information you're supposed to put on the back of the incident report. I've seen nursing-home admissions packets that didn't use up as many printer cartridges. For every single fall---no, that's every single unanticipated change in planes---I have to review the incident report and sign off on it. Then I check off a pageful of clues as to what may have contributed to the occurrence, e.g., 1) Was the resident wearing shoes? 2) Was that a puddle of pee, or a shot glass full of Jack Daniels she slipped in? 3) What language does the resident speak? 4) Why do we care if she swore in Portuguese or pig-latin??

Next, I fill out another checklist which lists some 20 different interventions (unfortunately, aerial spraying of Haldol and a one-way ticket to the nursing home aren't among them); write up a new fall-risk assessment form each time, even if the resident logs more time on the floor than a bathmat; and finally document my findings in a progress note. Then I get to make a copy of the progress note and attach all of the above to the incident report, as well as copies of the interventions which go in both the care-plan book and in the resident's chart.

I just slaughtered two trees, and I haven't even STARTED on the other five fall reports on my desk yet. The environmentalists are going to be calling for my head on a platter if this keeps up, I tell you. ~~~sigh~~~

So, I was bored a few days ago because I had only one fall report and three other incident reports to deal with, and on a whim I decided to call up our Corporate nurse consultant to pick her brains about how to manage this enormous increase in paperwork without spending half of the week pounding on my computer keyboard and the other half waiting by the printer. She's a good egg, is our Julianne (name changed to protect the beleaguered); she has this amazing ability to keep up with the rules and regs in 7 Western states and still maintain a semblance of sanity, but once in a while she loses her happy thoughts.......and when Julianne's not happy, ain't NOBODY happy.

She wasn't happy when I questioned the need for so many different forms to document this frequent occurrence in our building. Falls happen so often, in fact, that if life were a horizontal game, our residents would win it handily. We've tried every intervention in the book and then some, and we long ago ran out of ideas for keeping them in an upright position. Julianne, however, was in no mood to discuss it: "(Sister facility) was cited and put on stop-placement because falls weren't being properly documented," she huffed. "I don't care if it takes ten pieces of paper, these things have got to be documented and interventions have to be put in place or our buildings will get shut down."

It was on the tip of my tongue to mention that it was hard to come up with interventions to prevent resident falls when I couldn't get away from the computer long enough to actually go and assess the resident, but I kept that thought to myself. After all, I'm not a floor nurse anymore, I'm an administrative nurse: a pencil-pushing goddess who delights in new and novel ways to document everything that's not getting done because the goshdarned paperwork takes up so much time. Anyway, I did say that I thought some of it was redundant, and that while it had been of value in solving the mystery of why one particular resident was falling, it was a total time vacuum in light of the fact that our building was averaging 5-6 falls every week.

Julianne: "Well, falls are one of the top reasons why facilities are being cited."

Me: "I know that. I saw how things were done at (sister facility) and I learned a lot about what surveyors are looking for. Believe me, I've investigated every single incident that's happened since I started here, and that took up a huge amount of time as it was. How am I supposed to do all the other things I have to do as the DON if I'm filling out seven pages each and every time someone even THINKS about hitting the deck?"

Julianne: "The staff can do the contributing-factor checklist. You just have to put in the interventions and progress-note it. It's part of the job."

Me: "I know that. It's just an awful lot of paperwork for one incident that half the time is only someone being lowered to the floor by staff....."

Julianne: "Well, good documentation is what keeps our buildings full, and YOU out of court."

Oh.

Funny, I thought that slick marketing folks and a reputation for excellent care was what kept our buildings full, but I'm all about staying out of legal trouble, oh, yes Ma'am! I had an instructor in college whose few words on documentation have never been far from my mind: "Imagine, if you will, YOUR nurse's note on the overhead in a court of law.......YOUR documentation, writ large on the courtroom wall in black and white......" Well, that image put the fear of God into me then, and it still does.

Which is precisely why I shut the front door, thanked Julianne for her time, and hung up the phone so I could get back to the ghosts of Christmas trees past that were still stacked on my desk.

I wonder what they'll come up with next? In the meantime, I've created a couple of new forms that are helping me organize my assessment info and interventions for pain control, skin breakdown and wound care, diabetic management........

Nursing and The Art of Arboricide

About VivaLasViejas, ASN, RN

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