I hear a lot of different things about how often you should document and what you need to document. I work 12 hr nights and I document an opening noted, along with a RN shift assessment flowsheet and then notes or flowsheets every 2 hours as I do my rounds ( I will alternate a flow sheet with a note) and then I also document pain meds, treatments, reassessments or any education in my notes. I was taught in nursing school that if you don't document it then you didn't do it. I notice that some nurses will only document an opening noted (a basic note- pt rc'd and pt is in no pain or distress), their RN shift assessment, do flowsheets and document all meds and PRNs on the medication record. On the pt's chart it looks only as if they made one note all shift. So what was the pt doing the other 11 hours??? I feel more charting should be done... even if the pt is just sleeping. What do you all think? Our hospital policy says we should document with narrative charting. Thanks in advance for the comments.
I have a question. I had been taught charting by exception and if something was going on with a patient I was to include all parties at the bedside by name, such as Jane D. RN at bedside, or Kira CNA assisted patient to bed. This was common practice at the Hospital too. But recently I've started working at a skilled nursing facility and was asked by another nurse to not include her name in the documentation, and that even the doctors name does not appear in the nurses notes. (I'm still going to put the doctors name... I know better here) She asked I only document unit 4-East nurse as bedside, and it's just weird seeing her name in another nurses documentation. I don't understand this request, because if I'm pulled into court years later at least its specific to who assisted me at bedside.
Last edit by ginsil22 on Feb 9, '12