Why is charting so difficult and time consuming? - page 2
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... Read More
Jan 9, '07If 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.