Getting Nurses to Document

  1. Nurses are generally wonderful about pt education. My concern is the charting of it. We have a great Multidisciplinary Pt Teaching Form that is easy to read, fill out, locate (it's bright orange)and understand. I can't get the nurses at this hospital to remember to use it! I have had inservices, begged and reminded - but still continue to find charts that don't have anything charted on the education form by the nurses (PT, Resp, nutrition services, social services, etc. all do a GREAT job on their documentation on the form!) Help! I know nurses are super patient educators - how do I get them to write it down?
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  2. 9 Comments

  3. by   Marti Ann
    I know this sounds silly,but it works.rewards and praise.everyone want to be praised for a great job well done. we get blamed for doing so many things wrong, turn the tables around..go to an awards store and at the end of the month the nurse who has the most and best documentation gets an award, and little pin, lunch on the hosptial.a nice letter in their file. anything that shows they did a super great job.how about a massage for all the tension we have as nurses!!!!good luck.
  4. by   Sarah Kat
    Originally posted by Marti Ann
    I know this sounds silly,but it works.rewards and praise.everyone want to be praised for a great job well done. we get blamed for doing so many things wrong, turn the tables around..go to an awards store and at the end of the month the nurse who has the most and best documentation gets an award, and little pin, lunch on the hosptial.a nice letter in their file. anything that shows they did a super great job.how about a massage for all the tension we have as nurses!!!!good luck.
    That sounds like a great suggestion! I agree, everyone loves a pat on the back (whether they admit it or not). Positive reinforcement is a surefire winner.
  5. by   ssakd
    in my hospital,the multidisciplinary patient education form is the least used document,Nurses and the rest of the health team dont just document.The biggest problem is duplication of documentation,this is what has been voiced.We are expecting a NP from Carlifornia who promised to merge the tools to reduce the documentation workload.
    Last edit by ssakd on Jan 2, '07
  6. by   UM Review RN
    Quote from RebeccaC
    Nurses are generally wonderful about pt education. My concern is the charting of it. We have a great Multidisciplinary Pt Teaching Form that is easy to read, fill out, locate (it's bright orange)and understand. I can't get the nurses at this hospital to remember to use it! I have had inservices, begged and reminded - but still continue to find charts that don't have anything charted on the education form by the nurses (PT, Resp, nutrition services, social services, etc. all do a GREAT job on their documentation on the form!) Help! I know nurses are super patient educators - how do I get them to write it down?
    Sounds weird, but try putting the Pt Ed form directly on the other side of the nurse's notes or even on the flip side of the divider to the nurse's notes. No flipping around, less charting, less searching for the right place.

    You need to remember that we're in a constant time crunch in a business where mere seconds can make a difference between life and death.

    This is a really old thread, but still relevant in my workplace, so that's why I responded.
    Last edit by UM Review RN on Jan 2, '07
  7. by   gun
    it is same in my settings too, we educate the patients but fail to document it.It is mainly due to shortage of time as we are very less in numbers who is taking care of the patients.
    like Marti Ann said that reward is the best solution, as every boby likes the pat on the back for good work
  8. by   IckuRN
    We have handouts for pt edu, and with each one we print, we get an extra sheet to put in the chart under care planning to prove we did it. No one uses this all the time either, but I think it's cool.
    Anyway, I had a manager once that did a little praise here and there, but we got bright yellow chart audit reports weekly. He checked the charts and made a "**** list", with the date and shift listed of what was missing. It was up to us to save ourselves, and it worked well, because nurses like to blame each other for everything.
    Last edit by tnbutterfly on Mar 25, '08 : Reason: TOS language
  9. by   Flame_07
    I agree about rewarding. I was one of those nurses who always forgot to document education. In a unit meeting the nurse manager stated it was something that was going to be looked at for the next 2 months and there would be rewards for 100% compliance. There were 3 nurses who received nice rewards when she announced this. It's just not the reward but just knowing that if it's not documented it's not done and wanting to be in compliance has made me always go to that area of charting. Oh I didn't get and award at the next meeting but I was in 80% compliance and just the recognition keep to striving to do better.
  10. by   jjjoy
    Quote from RebeccaC
    (PT, Resp, nutrition services, social services, etc. all do a GREAT job on their documentation on the form!)
    PT, Resp, Nutrition, Social services all see patients one a time and chart what was done immediately after their patient contact. Nurses are juggling several patients all day all at the same time and are constantly getting pulled away from whatever task they were initially heading to do and not able to get back to other tasks til who know when. It's no wonder nurses' documentation is spottier than the others'.

    How to improve it? As others have noted, if you can audit education documentation for awhile and periodically in the future, give feedback to each individual about their % completion of that, and praise/reward that documentation, then the nurses will be more likely to complete that documentation in the future. First of all, they know that someone IS really looking at it. After all, nurses have SO MUCH else to do and if they've done the education and figure that no one really checks that documentation, it's more likely to fall off the bottom end of their to-do list. Also, it's difficult for most people to accurately gauge their % compliance with that type of documentation. Seeing an actual count of one's % completion can be a real eye-opener and providing on-going feedback on their performance can allow the staff to be able to concretely see if they've made an improvement.
  11. by   softstorms
    I have to say where I work we have great feedback from all the sources mentioned above. What we don't have is time....Not time to do it, but uninterupted time. While all the above have offices and computers to do all this, we as nurses have a desk on the front door of the patients. As we try to do the charting you need we are interuppted 10 times to answer questions and do tasks. So the charting gets lost in the tasks. I often think if I had one hour of time, I could give you more of what you need.

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