can your DON tell you to completly change how you chart?

CaringGerinurse525 · May 9, 2015

I recently got a new boss. She reads the nurses notes that were written the day before. I have no problem than that. The thing that I am unsure about is we are now being told not to use any words that are in the past tense. I work 12 hour shifts it is impossible to sit down and chart for the first four hours because I haveto pass my own meds. Thoughts please.

Can you give an example of something she finds incorrect?

Animal House R.N., ADN, CNA, LVN · May 9, 2015

That I need to write patient with food instead of patient had food. We are not to use had because it is past tense.

enuf_already · May 9, 2015

So you are supposed to write that the patient is having a bowel movement and give a narrative as if you are watching it happen in the present tense? That would mean you could not chart that the patient voided, was incontinent, slept, returned from somewhere, had their linens changed, were bathed, etc.

Maybe your manager can write a typical day's narrative to show you how this can be done. I think this may prove very difficult.

Animal House R.N., ADN, CNA, LVN · May 9, 2015

Thank you

CamillusRN, BSN · May 9, 2015

I'm not sure how that could possibly work out. Can you use late entry notations and chart in the present tense that way? Either way, sounds like there needs to be a little bit more clarification on the part of your DON.

CapeCodMermaid, RN · May 9, 2015

I'm completely baffled by this. Been doing this for more than 30 years and this is a new one for me AND I have a degree in English and am a member of the Grammar Police so I know it can't be that. Has anyone asked her?

heron, ASN, RN · May 10, 2015

Does the DON come from a more acute setting that requires documentation of frequent (ie q2hr) observation? If so, she may consider such concurrent charting more "valid" than a retrospective narrative note written at the end of the shift. Unrealistic in LTC, to say the least, if not flat out dishonest.

Here.I.Stand, BSN, RN · May 10, 2015

How are you supposed to document your interventions and response if you can't use past tense?

"Resident is being incontinent of urine in the bathroom and is slipping on the urine as she is standing up; resident is falling to the floor. Resident is not hitting head. This writer and CNA are helping the resident back into wheelchair. Resident is complaining of pain in Rt knee 5/10. Writer administering prn Norco and applying an ice pack. One hour later, resident's pain is 7/10. Writer is noting that the knee is more swollen than it is as the resident is falling. Writer is contacting MD, reporting findings. MD is ordering an x-ray; tech with the resident at this writing."

That is some GOOD response time if the resident is falling and the tech is already performing the needed x-ray. :wacky:

See what I mean by this made-up-on-the-fly note, though? The notion of writing all notes in present tense makes no sense. I work in an ICU where we monitor from frequently to continuously, and we write narrative notes at least partially in past tense all the time. Our standard is the DARP format: data and actions are all past tense. Response is present tense...or actually it could be past tense, too; e.g. 10 mg labetalol was effective at bringing SBP to ordered goal

allnurses Guide · May 11, 2015

I recently got a new boss. She reads the nurses notes that were written the day before. I have no problem than that. The thing that I am unsure about is we are now being told not to use any words that are in the past tense. I work 12 hour shifts it is impossible to sit down and chart for the first four hours because I haveto pass my own meds. Thoughts please.

On at typical day in the LTC I am passing meds and doing treatments of anywhere from 9 to 13 patients inan 8 hour period. That includes breathing treatments, bolus feedings, wound care and dressing changes as well as attending to the dignity of our hospice patients. This is how I break down my shift.

1. Get report

2. Take vitals and blood sugars

3. Chart vitals and blood sugars at the computer on my medcart (standing)

4. Give insulin and 1st riund or meds - again charting as I go.

5. Break for lunch eat, come back to the unit and chart a bit more in the nurses station before doing 2nd med pass.

6. Repeat three and four

7. Repeat 2 and three for before dinner insulins and after dinner meds.

8. return with my cart to nurses stationa and finish uo my charting.

9. Tidy and stock my med cart for next shift

10. Give report and go home.

11. next day rinse and repeat.

The trick is to chart as you go in the present tense all findings, interventions and effectiveness of those interventions. You have to be able to set your priorities and manage your time. In my facility CNA "Do NOt Take Vitals" per the management they have enough to do. But the ones I work with will if I ask nicely and no one is looking.

Peace

Hppy

allnurses Guide · May 11, 2015

Example "Resident's vitals are BP,P,R,Pain, 02 sat. Also SOB applying oxygen at two liter's per Phys order. O2 sat is improved"

AnthonyD · May 12, 2015

So you are supposed to write that the patient is having a bowel movement and give a narrative as if you are watching it happen in the present tense? That would mean you could not chart that the patient voided, was incontinent, slept, returned from somewhere, had their linens changed, were bathed, etc.
Maybe your manager can write a typical day's narrative to show you how this can be done. I think this may prove very difficult.

Exactly! This doesn't even make sense. At least, I can't see the logic in it.

I'd love to see her write "The patient is falling out of bed onto the floor." The implication being, "I'm sitting here writing this note while I watch my patient fall on the floor, rather than getting up to prevent it."

Or better yet. "The patient is having an unwitnessed fall while attempting to ambulate to the bathroom." (My psychic powers are strong today.)