Anyone have too much paperwork???

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at my LTC facility i have never seen so much paperwork...there must be a form for every little thing. Everything that happens to a patient and as we all know in a days time you could have 3 or 4 patients change from having a low/high blood sugar to low bp to passing out to going to the e.r. to being put on ABT for UTI. etc. we have to fill out a change in resident status forms..anyone else???for everything it slows up my day so much:rotfl: and the nurses on my floor are more concerned with the paper work than the patient b/c they are scared they are going to get in trouble from administration. For example, I sent a patient out to the ER for resp distress and called the doc,family, wrote a note etc. and the next day the night nurse said to me did you do a change in resident status form???? I did do one but what happened to how is Mr. so and so instead it is replaced with did you do this form..I feel like the nurses can not critically think at all b/c of administration,,they dont want them to critically think and i am finding myself sinking into the same trap,,,it is scary and i feel like i am in a cult..i cannot use my own nursing judgement that when a patient's bp is low and not symptomatic i will take it in one hour and hold their bp meds..instead they want us to fill out a sheet for every little think...i am frustrated....:rotfl:

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Yep...seems like as soon as one form comes out they want you to do another...or a new DON starts with new forms. Happened to us a while back. What ever happened to the report sheet? If everything is on that, (change of status, DC, admits, new orders, etc) that should be enough! Night shift copies it and sends it out to the different department heads.

IF they all read this, this should be enough communication, instead you have to issue personal invatations for them to read the report? No wonder things get missed. Duh!

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Who is all that paperwork for anyway?? Who sits up at night reading it? Yeah, yeah, I know - what if we were to go to court?? All I's dotted and T's crossed right? But at who's expense?? I've decided that most important is my patients - they come first. If someone has a prob with that, they can stick it. I'll fill out all appropriate forms when I have a free minute (free minute, what's that??). Somethings are more important than others. My patients will not suffer beause we think we should destroy a rain forest for the proper forms...that lay dormant in the bowels of the hospital down an elusive hallway in a faraway land called medical records.... :angryfire :bowingpur :no:

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Thumper HAHA! Right on!

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Specializes in MDS coordinator, hospice, ortho/ neuro.
Who sits up at night reading it?

State surveyors, MDS co-ordinators who pipe the data to the State so your facility gets paid, Quality assurance, your facilities insurance (liability) carrier, the patients insurance company, infection control, the nurse 2 shifts from now who did not get a decent report from the nurse before her..............................

A lot of it is duplicated effort.....but sometimes you get some nurse to think about what is really going on when they fill out that Fall Risk Assessment and they start to think about factors that were ignored before.

I'm hoping that when computerized charting gets more common, and gets into our facility that it will be user friendly enough to cut down on the duplicated forms ( ie.....diet change order gets entered one place and automatically gets sent to all the places it needs to go).

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A lot of it is duplicated effort.....

I'm hoping that when computerized charting gets more common, and gets into our facility that it will be user friendly enough to cut down on the duplicated forms ( ie.....diet change order gets entered one place and automatically gets sent to all the places it needs to go).

Maybe that's what it is - duplicate charting. I just think that there is WAY TOO MUCH emphasis put on all this charting that the pt's don't get the care they are supposed to have. My gosh, an admission at the hospital carries a stack of papers 1/2 inch thick!! I am the RN responsible so I have to take an extra hour to go through every piece with a fine toothed comb to make sure every box is filled and every form dated?!? Yes, that is what I have to do, isn't it? Not to mention all the post-op paperwork, teaching packets, no-smoking surveys, discharge papers, medicaton reconciliations, etc, etc,

etc.......gee, I hope my bed-jumper hasn't fallen, my incontinent pt's skin isn't broke-down, my confused, combative pt hasn't slipped out of her wrist restraints..again, my brittle diabetic isn't slipping into DKA..shall I go on?? I know what the paperwork is for, and I know who it is for, but I am sick and tired of staying 2 hours after my shift is over completing it all. I'd rather get high marks for being a nurse, not for penmanship.

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We have a form for everything too. But my favorite (yeah right) is the new order and lab binders. Anytime we take a telephone order we are supposed to write the order in these binders. It's supposed to keep us from making mistakes, but it is just so much repetition. We give the DON a copy of the T.O. I would think that would be sufficient. I've never worked in a hospital setting, but isn't everything on the computer as far as documentation goes? I'm just praying that there will come a day when LTC facilities change to that.

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I've never worked in a hospital setting, but isn't everything on the computer as far as documentation goes? I'm just praying that there will come a day when LTC facilities change to that.

We are still in the process of switching over to computers. Labs, mars, diets, and so on are on the computers, but our charting is still by paper as are our doctor orders, we're supposed to be going to computer documentation in the next few months (yee-haw), though personally I don't like our computer system. SO, therefore, am double charting like nobody's business at the moment. Hopefully at least when the system is finally up and running there won't be quite as many forms, but that's also probably wishful thinking.

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uhh, we have computerized charting. One of our nurses wanted to break down the time spent with patients and the amt of time paperwork takes up per patient, the results, approx 1.5 to 3 HOURS of paperwork per patient per shift. This translates to a lot of money!!! If you have 7 patients on a 12 hour shift, well i think you get the picture. And add to that three discharges, to admits, and one post-op, you are in pretty deep. This research that she completed was the cornerstone argument for adding a new position --- an admissions/discharge nurse (of course this is a trial position, but believe me we are charting our butts of to prove how much she is needed!). Thank goodness, it has made all the difference.

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uhh, we have computerized charting. One of our nurses wanted to break down the time spent with patients and the amt of time paperwork takes up per patient, the results, approx 1.5 to 3 HOURS of paperwork per patient per shift. This translates to a lot of money!!! If you have 7 patients on a 12 hour shift, well i think you get the picture. And add to that three discharges, to admits, and one post-op, you are in pretty deep. This research that she completed was the cornerstone argument for adding a new position --- an admissions/discharge nurse (of course this is a trial position, but believe me we are charting our butts of to prove how much she is needed!). Thank goodness, it has made all the difference.

What great research!! We have 2 admission/discharge nurses, but when you are talking about a 5 floor hospital, that's not really very much help. Especially when you consider that we have approx 10 discharges and 10 (at least) admissions a day and that's just my floor. Oh, well, what can you do? :o

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Specializes in Gerontology, Med surg, Home Health.

Thumper, you mention wrist restraints?!?!?! Surely you couldn't work in a LTC setting and be allowed to use wrist restraints.

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