Why is charting so difficult and time consuming?

BJLynn · Jan 9, 2007

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 · Jan 9, 2007

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

chenoaspirit, ASN, RN · Jan 10, 2007

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.