Charting has to be done no matter what?

Specialties Geriatric

Published

Most of the nurses at my job do their daily required charting each day. However, we have a few nurses who don't do their daily required charting. Management is now telling us that all charting has to be done period. For example, if the other shifts did not do their required charting then they want someone from another shift to do that person's charting for them. For example, the 7-3 nurse did not do some required charting on her shift. So the supervisor tells the 3-11 shift nurse to do the 7-3 nurses required charting. Is this something new or do all LTC facilities do this now?

Specializes in Psych ICU, addictions.

The ONLY way I would chart something for another nurse is if it was made specifically clear that these were not my observations/findings, but another nurse's, (e.g., "per previous shift RN, ...", or "per staff report, ..."). And that would only be if that information happened to be very pertinent to what was going on during MY shift.

Otherwise, no way in hell.

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Specializes in ED.

So true story.

I received an email from the "documentation committee" (5 RNs who do nothing in our short staffed unit but pore over our charts to find things on their co-workers. gleefully. but somehow their own charts never get pulled for review...) about a pain re-assessment that I somehow forgot to do with my 5:1 Level 1 trauma load--2 criticals and 3 beds that flipped ridiculously fast.

Email reads: Titanium, on pt XYZ four days ago, you forgot to do a pain reassessment after you administered 650mg of tylenol. Please go back and put that in, and when you are done, please email me to assure me that this has indeed been taken care of.

I wrote back: Dear Chart Police (didn't really say that but felt like it). First, I have zero recollection of this patient from 4 days ago. What their pain reassessment was from their life saving Tylenol admin, because I was busy with my intubated crushed skull kid and my refractory SVT old lady. sorry I wasn't that attentive to XYZ who was here for 45 minutes. Second, I did go back into EPIC just to see if I could even add anything to that chart at this point, and amazingly, you can't do stuff like that 4 days after the event. Imagine my surprise.

So, chart person, how would you like me to falsify the record at this point? Please email me with a detailed explanation on how or why I would ever chart something that I probably did not even do?

Suffice it to say, I did not receive an answer. Lemme tell you....this crap about "have you ever had to justify yourself in court over a chart entry????" HUH? HUH?HUH??????? Is just that. Crap. I haven't met one person in my unit that's been called into court over anything. At all. I knew RNs that their charting was LITERALLY....pt arrived. they're breathing. gave this med (sometimes scanned, but mostly overridden). pt left.

And nobody did a damn thing. I've taken over pts that have 2-3 lines, a chest tube and a foley...and not one thing is documented. Do I do that myself? NO. It's bad business. But is this the be-all and end-all of your nursing shift? If you are one of the unfortunate ones who are on a unit that has a micro-manager, I'd say start looking quietly for another job. I think that if you chart in a reasonable manner, then you are fine.

Management uses "court" as a scare tactic. Management follows the law when it's convenient for them...when it's gonna cost them money in the end if you don't tighten it up. Do your best, follow the policies of your hospital/facility to the best of your ability and to hell with anybody else's charting. That's on them. Believe me when I tell you, no matter how well you chart, it will never be good enough for management. They want all of your time accounted for---since you know....all we do is sit around and eat pizza while perusing facebook.

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Specializes in LTC, Rehab.

That is insane. How can a nurse on a later shift describe exactly what happened on a previous shift? I don't even always do MY required charting, much less another shift's. I do as much as I can every day, but if it's already 30-45-60 minutes after the end of my shift and I still haven't charted on every person I'm supposed to chart on every day (not to mention those who I need to chart on because something happened, whether they're one of my 'must-chart-on' ones or not), I sometimes just have to leave regardless, you know?

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Yes, I am wondering why management is not stepping in and getting these nurses to do their own job. I can barely get my own charting done and then I am expected to do someone else's charting too?

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You can't win. They say you have to do your required charting. Of course, if you have to do "overtime" in order to finish all of your required charting then you are "the bad guy" for having overtime.

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Specializes in Telemetry, Step-Down, Med-Surg, LTC, PACU.

Hahaha. I am seeing this more and more, not to mention being asked to go do documentation like 10 - 20 days back... Are you kidding me?

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Specializes in LTC and Pediatrics.

The places I have worked and have to chart for Medicare residents, they ask that it be done every shift. The reasoning seems to be that if one shift didn't get it done, then it will get done on another and they have their one assessment/charting for that day.

I also find that facilities start to get really picky when they are due for state inspection.

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