Steady Drip of documentation

Nurses General Nursing

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Specializes in vascular, med surg, home health , rehab,.

Are the rest of your facilities doing this? The past 12 months they have steadily added more and more documentation requirements. Dvt risk assessment every shift, now a suicide risk assessment, full admit assessment and a post op eval on all post ops (great that a pt isn't assessed before surgery), q 15 min charting on anyone in restraints, paper plus q 2 in the computer. Q 12 hrs chart checks, a chart audit monthly. Now, hounding the docs to dc antibiotics on surgical pts within 24 hrs. A med reconciliation form they have to sign on admit and dc; of course, they have to be chased down on the dumb things they circle, yes to iv fluids when there going home, etc. A flu and pneumonia shot screening on admit. A steady drip thats becoming a flood. Add to that increasingly higher acuities, how do they thing we can get all this done in 12 hours, plus actually do the care they claim they want for the pts? :madface:

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Specializes in LTC/Rehab,Med/Surg, OB/GYN, Ortho, Neuro.

I know what you mean. I had a pt's family member ask me questions about nursing one time (she was thinking about going into nursing school). I don't remember all of the conversation, but I do remember telling her that nursing would be perfect if it weren't for all the paperwork (I was sorta joking). She said "Really, nurses have to do paperwork?" I replied "Yes. As a matter of fact, for the 20min that I've been in here, I'll have about 20-30min of charting to do." Her reply? "Oh, never mind then. I don't want to be a nurse no more. I thought all you did was give people medicine until you found a doctor to marry." :uhoh3: :uhoh3: I should also mention that this family member had a cousin who was an RN (who was the most useless.. you get the idea) and she was married to a doc. I wonder where she got the idea from?

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Unfortunately, once a form is introduced, it is there to stay. Multiply each form to be done by the number of patients you have, and struggle under the added burden. There is a trend towards "quantifying" and measuring what nurses do. Of course if we are spending more time filling out forms, that leaves less time for patient care.

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Specializes in Med/Surg, Geri, Ortho, Telemetry, Psych.

There is constantly new documentation requirements. There's nothing wrong with that. Most of the time it's to cover the facility's butt, but in the process you are also covering your own.;)

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AnnMArieRN--Do you care to say where you work, or at least what city? Everything you mentioned (DVT & suicide screens, etc.) makes me think we work for the same place. Well, used to anyway. I'm no longer there partially due to the insane amount of charting required.

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Specializes in vascular, med surg, home health , rehab,.

HCA. As for protecting myself by charting, I disagree. If I am allowed to do my job the way it is supposed to be done, I think I would have far less to worry about. Short of resigning myself to be there 14-15 hours a shift, shortcuts have to be made, pt care suffers and it stinks. CYB is all anyone seems to care about. Sad and scary. One day we all will be that pt in the bed, whose nurse is busy charting and doing all the juggling we do every day, to be there for us.

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My Facility has addded " 24 hr chart check completed" on every chart every night, This is another 2 hours taken away from my patients. :rolleyes: :typing

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Specializes in Tele, Renal, ICU, CIU, ER, Home Health..

I agree that the amount of charting it outrageous. I would like to point out, though, that "They" is JCAHO. As a member of the JCAHO Committee at my hospital I finally understand why all these forms are required. I used to think it was just some idiot in administration thinking things up for us to do. That's not the case.

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Specializes in Med/Surg, Geri, Ortho, Telemetry, Psych.
HCA. As for protecting myself by charting, I disagree. If I am allowed to do my job the way it is supposed to be done, I think I would have far less to worry about.

I agree with you that we are taken away from the bedside too much, but when it comes to a court of law, if we didn't chart it, we didn't do it. Can you save some of this charting until the end of the shift?;)

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Some things that are to be charted, though, are ridiculous. One of the things that was brought up in my termination meeting was that I didn't use the nursing ladder and call for help. I did, and when I argued that point vehemently I was told, "But you didn't chart that you called for help."

Wha......??????

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Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

Tazzi that's what they say ain't it? not written not done. Oh sorry I didn't have time to call for help because I was charting I was going to call for help........yeeeeech. YES too much "paper" even if it is on computer now.

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I just didnt understand how my calling the house supe for help (and the fact that she didn't respond) belonged in the pt's chart???

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