charting phobia

  1. anyone have any tips on charting, its my biggest:imbar problem, I know I'm gonna make a great LPN(I really enjoy taking care of pt's), but I am hopeless at charting!!!!!! any advice, tips, books on charting would be soooo appreciated :}
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  2. 9 Comments

  3. by   Cyndi-LOTR-Fan
    I can tell you that charting is your greatest friend and guardian against liability. Let me tell you my little story:

    I'm an LPN in FL. The nursing instructor I respected the most, who was also a real stickler for charting, drummed it into our heads: CYA (cover your ass-ets) and chart as much as humanly possible, and THEN some, espcially if you have a problem with your supervisor not listening to your concerns about a patient, which is what happened to me one day.

    The RN thought she was the only busy one there that day, but I saw that I had a patient that was taking a turn for the worse. I told her he was taking a turn for the worse, then watched to see if she came to look in on him. She didn't. I kept going back to tell her, each time more urgent than the last--still she wouldn't check on him. I'll give you an abbreviated account of my charting that day, leaving out the medical bits because that would be too long:

    12/02/2000 1300 hrs: ...advised RN NeverListens.
    12/02/2000 1315 hrs: ...advised RN NeverListens.
    12/02/2000 1300 hrs: ...advised RN NeverListens.
    12/02/2000 1325 hrs: ...advised RN NeverListens.
    12/02/2000 1330 hrs: ...advised RN NeverListens.
    12/02/2000 1335 hrs: ...advised RN NeverListens.

    By 1335, I was at the patient's bedside as he coded, luckily. The call light wasn't working of course, nor was the intercom that was connected to it, so I had to run out into the hall and yell for her & others to come, after I called in the code.

    The RN comes in and was immediately looking to pin everything on me. The crash team was there working on the patient, was able to save him, and all the while the RN was doing everything she could verbally to make me look like the one who had neglected him. She even said I ruined precious seconds because I didn't pull the call light out of the wall, which makes the emergency light blink, for pete's sake!

    Remember how we are instructed to keep out of the crash team's way when they arrive, unless there are tasks you can do, or they ask for help? During that time, I had already charted the above about the light being broken, and calling the code @ such & such hours, and what I had done to help the patient. The crash team, listening to this RN, frowned at me and picked up the patient's chart right before the RN grabbed it, and there was nothing she could do to back up her lies because I had already charted everything right above the notes the crash team had added.

    She was busted, my career & good name was safe, and most importantly, the patient was safe.

    Maybe he was better off she had not looked in on him, because I looked after him with an even closer eye.

    I'm not saying every RN is bad, heavens no! I am saying that you will definitely have co-workers and supervisors who will send you up the river if you aren't careful, so chart-chart-chart, especially on the dangerously ill patients...I know it is more of a challenge now than ever before.

    I probably won't remember to check back here for messages on my post, because since then I've contracted a neuro disease that left my career behind me as my short term & long-term memory became hampered, so please don't think I'm ignoring you if I do not answer. I just wanted to tell this to you, so you keep it in mind in case you end up with a similar situation...and chances are too good that you will!

    -Cyndi
  4. by   pedinurse05
    Quote from lmagsay
    anyone have any tips on charting, its my biggest:imbar problem, I know I'm gonna make a great LPN(I really enjoy taking care of pt's), but I am hopeless at charting!!!!!! any advice, tips, books on charting would be soooo appreciated :}
    A good rule of thumb is to use the nursing process to guide your charting. Chart the problem, intervention, outcome and pt response. Remember this to help you...AIR A=Assement I=Intervention R=Response. You will get the hang of it the more you practice.
    Good Luck as you start your new career!

    Missy
  5. by   pedinurse05
    Quote from Cyndi-LOTR-Fan
    I can tell you that charting is your greatest friend and guardian against liability. Let me tell you my little story:

    I'm an LPN in FL. The nursing instructor I respected the most, who was also a real stickler for charting, drummed it into our heads: CYA (cover your ass-ets) and chart as much as humanly possible, and THEN some, espcially if you have a problem with your supervisor not listening to your concerns about a patient, which is what happened to me one day.

    The RN thought she was the only busy one there that day, but I saw that I had a patient that was taking a turn for the worse. I told her he was taking a turn for the worse, then watched to see if she came to look in on him. She didn't. I kept going back to tell her, each time more urgent than the last--still she wouldn't check on him. I'll give you an abbreviated account of my charting that day, leaving out the medical bits because that would be too long:

    12/02/2000 1300 hrs: ...advised RN NeverListens.
    12/02/2000 1315 hrs: ...advised RN NeverListens.
    12/02/2000 1300 hrs: ...advised RN NeverListens.
    12/02/2000 1325 hrs: ...advised RN NeverListens.
    12/02/2000 1330 hrs: ...advised RN NeverListens.
    12/02/2000 1335 hrs: ...advised RN NeverListens.

    By 1335, I was at the patient's bedside as he coded, luckily. The call light wasn't working of course, nor was the intercom that was connected to it, so I had to run out into the hall and yell for her & others to come, after I called in the code.

    The RN comes in and was immediately looking to pin everything on me. The crash team was there working on the patient, was able to save him, and all the while the RN was doing everything she could verbally to make me look like the one who had neglected him. She even said I ruined precious seconds because I didn't pull the call light out of the wall, which makes the emergency light blink, for pete's sake!

    Remember how we are instructed to keep out of the crash team's way when they arrive, unless there are tasks you can do, or they ask for help? During that time, I had already charted the above about the light being broken, and calling the code @ such & such hours, and what I had done to help the patient. The crash team, listening to this RN, frowned at me and picked up the patient's chart right before the RN grabbed it, and there was nothing she could do to back up her lies because I had already charted everything right above the notes the crash team had added.

    She was busted, my career & good name was safe, and most importantly, the patient was safe.

    Maybe he was better off she had not looked in on him, because I looked after him with an even closer eye.

    I'm not saying every RN is bad, heavens no! I am saying that you will definitely have co-workers and supervisors who will send you up the river if you aren't careful, so chart-chart-chart, especially on the dangerously ill patients...I know it is more of a challenge now than ever before.

    I probably won't remember to check back here for messages on my post, because since then I've contracted a neuro disease that left my career behind me as my short term & long-term memory became hampered, so please don't think I'm ignoring you if I do not answer. I just wanted to tell this to you, so you keep it in mind in case you end up with a similar situation...and chances are too good that you will!

    -Cyndi
    Personally I would never chart "never listens" as this is how you viewed this. She may have indeed heard you but obviously didn't act upon in. "Never listens" is subjective. I personally would have charted something like primary care RN notified of change in pt condition (and put down those assessments, like increased resps at 40...whatever it was). I also probably would have notified the charge and documented this in the same fashion. I always try to only chart facts and not what I perceive something to be. I have heard before of nurses charting pt. sleeping and indeed the patient had expired. A better way to chart is pt. resting with eyes closed. Resp 16 easy and unlabored (or something similar). Avoid assumptions or passing on opinions in your documenting.
    Missy
    Last edit by pedinurse05 on Nov 16, '05
  6. by   slinkeecat
    Missy...
    She charted Notified RN "neverlistens" .... neverlistens as being the rn's name...lol
    To the original poster:

    The Nursing made Incredibly easy... book series has a book about charting which is really good and I recommennd to many of the graduate nurses that hit our doors.....
    It's .... Charting made incredibly easy...

    Missy's advise about AIR ... it is very good advise....
  7. by   pedinurse05
    Quote from slinkeecat
    Missy...
    She charted Notified RN "neverlistens" .... neverlistens as being the rn's name...lol
    To the original poster:

    The Nursing made Incredibly easy... book series has a book about charting which is really good and I recommennd to many of the graduate nurses that hit our doors.....
    It's .... Charting made incredibly easy...

    Missy's advise about AIR ... it is very good advise....
    LOL! Now that I took the time to read the post better I see that she meant that as a name One of those long days! I agree the incredibly easy series are great! I have the charting one as well as the EKG...great books that are so easy to read!
    Missy
  8. by   juvynurse
    Quote from slinkeecat
    Missy...
    She charted Notified RN "neverlistens" .... neverlistens as being the rn's name...lol
    To the original poster:

    The Nursing made Incredibly easy... book series has a book about charting which is really good and I recommennd to many of the graduate nurses that hit our doors.....
    It's .... Charting made incredibly easy...

    Missy's advise about AIR ... it is very good advise....
    Ohmigosh!! I took it that RN "neverlistens" the same way Missy did. I didn't ever think it was her name. I'm glad you cleared that one up. I too worked with a nurse who would put:

    12/02/2000 0120: pt. sleeping. "nurse whatshername"
    12/02/2000 0330: pt. sleeping. "nurse whatshername"

    People told her all the time that one of these times, she's going to get into real trouble just charting "Pt. sleeping". I've always been the one to chart, patients eyes closed, breathing unlabored, resp 16. Bedside rails up. call light in reach. I don't want there to be a doubt in anyones mind that I didn't go in there and not check.

    One thing I remember when I chart is to chart for me. If I ever get called on the stand and have to defend my charting, I want to make sure that I've charted so I know EXACTLY what I did. I chart as if I'm talking to myself. Does that make sense? I was always told if it wasn't charted, it wasn't done. And that would hold up in a court of law. I never use the words "appears" or "seems". Pt. appears to be sleeping. Pt. seems to be tolerating medication. I've known nurses who do use these words and it just seems too subjective to me.

    In nursing school, my instructor told me I charted too much. Bless her heart, I can't imagine not charting too much, but I can imagine not charting enough.
  9. by   lmagsay
    thankyou sooo much, I will apply all the good advice, I only have 28 more days to go and then its final finals,I can't wait,
    Lynda
  10. by   mc3
    I'm glad I'm not the only one who thinks I chart too much...I also hear my instructors voice saying "if it wasn't charted, it wasn't done". But, I work with some folks who say the less charting, the better. Go figure.... I'm going to get the book......

    mc3
  11. by   sasha2lady
    @ my facility we cant chart that someone is impacted..we have to reword it differently...not sure why..they've never really explained that one. A recent thing i was notified of the other day at a nurse mtg was that one of my pts family members was threatening to call state on us ..said she pays good money to be there and isnt taken care of which is .....so not true..this pt is extremely combative in the am and we dont have a lot of issues w/ her or her family on my shift...in fact we find her family quite pleasant...except for a son who isnt there much..which is who i figure was the threatener in this case and he has no legal say so in his moms care.....i suspect guilt on his part...however....since then i keep her chart out my entire shift so that if she does have any behaviors or if the family that comes in every single day has a concern i can chart it....otherwise i have been charting on her every night how she has been on my shift and which family members have been there with her etc. ..........he can call state all he wants to...when they come in and check her out...they will find nothing and he will look like the idiot that he is. it kills me to see how the ones that never come by only whine and complain when they do come in. I would think they'd enjoy the time they get to spend with their mom/dad....but i guess it just doesnt always work out that way.

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