Why is charting so difficult and time consuming?

[Soup Turtle]

What, exactly, is involved? I'm hoping to be a student in a nursing program this March. I have two aunts that are RNs and I've been driving them nuts with all my questions! Now, I'd like to drive you'll nuts, too!:chair:

[BJLynn]

Ok, say I'm in my med room and a doctor rings up with a telephone order. I jot it down, then write it in the MAR or TAR. Then I have to go to that floor's case file room and write out a telephone order. While I'm in the resident's chart, I chart it in the nurses notes. Then I go downstairs to the nursing office and write out the order on the Physician Order Sheet. Then I turn around and write it on the shift report. If it is an antibiotic order, I write it on the antibiotic board (big ole dry erase board so we can see at a glance who's on antibiotics for what). Then I write it on the infection control log. I then have to check the emergency box provided by the pharmacy to see if the drug is there. If it is, I take out the needed dose(ages) and fill out that sheet. Then I get to chart in the nurses notes again that I initiated said drug. Oh, and I have to either fax the pharmacy, or ring the pharmacist to order the script.

And if it's not an order, we still do narrative charting. Plus seizure logs.

[jimthorp]

Blame it on our litigious society. I chart by exception.

[chenoaspirit, ASN, RN]

If you dont chart something, its the same as if you didnt do it. If the patient decides to take you to court and you tell them that you did a dressing change at a certain time and you didnt chart it, well legally you didnt do it. I do not chart each time my pt c/o pain because we have a flowsheet just for this, although I do chart the first complaint and what I administered, then just chart "please refer to pain assessment flow sheet and MAR for further details of c/o pain". We use focus charting. I always chart SOMETHING at least every 2 hours, even if its "pt resting with eyes closed, no acute distress noted, o2 sat 98 on 2 liters NC. Will continue to monitor" This at least shows that I was in the room and checked on them.