Caring for the Chart or the Patient?

[Brian, ASN, RN]

This is from a blog post from the NY times by Theresa Brown, R.N.

The mantra we all learn in nursing school is, "If it isn't charted, it isn't done," an impossible rule to satisfy. Since what could be charted is infinite, I begin each shift feeling that I have already failed in my documentation.

Hospital nurses are required to do paperwork, or "chart," throughout each shift. We do a full assessment of each patient at the start of a shift, and chart that on electronic flow sheets packed with a dizzying array of drop-down menus. If we have time, we document discussions with doctors, when a patient left the floor and when she came back and how we responded to an abnormal vital sign.

The mantra we all learn in nursing school is, "If it isn't charted, it isn't done," an impossible rule to satisfy. Since what could be charted is infinite, I begin each shift feeling that I have already failed in my documentation.

In addition to charting the events of the day, there are required pieces of documentation that address the concern of one health care agency or another. In 2005, the Joint Commission for the Accreditation of Healthcare Organizations put "falls" on their national patient safety list, so our charting now has to exactingly detail our commitment to fall prevention. The Centers for Medicare and Medicaid Services will not reimburse the cost of treating bedsores that develop during a hospital stay, so a new drop-down menu charts whether a patient is at risk and whether they have pressure ulcers already.

Full Story: http://well.blogs.nytimes.com/2011/02/02/caring-for-the-chart-or-the-patient/?ref=health

[INLPN93]

Try being a LTC nurse who is to electronic chart AND paper chart: VS, neuros, falls, bruises/skin tears/red peri areas and any incident or injury, MD calls with/without orders, family concerns, LOA and return with skin issue checks, changes in condition, accu-cheks below 60 or over 400, medication/tx refusal, neb tx with assessment, g tube placement verification/documentation, decub improvement/assessment. And multiply that x's 23-25 residents depending on assignment. Then add a 3 hour med pass, 1.5 hours in the dining room feeding and observing.....

When presented with this train of thought, failure is expected not an option. Nursing is hard enough no matter where you are these days.

[nursejoed]

"If it isn't charted, it isn't done."

Well, just because it was charted doesn't mean it WAS done....

[mama_d, BSN, RN]

I had a horrible shift the other night b/c we were so short staffed. Didn't even start my charting until after I got done giving report in the morning. I was almost two hours late coming home, and when hubby asked me what was going on to make me so late, he just couldn't understand how it could have taken that long to chart on five pts when I did the absolute bare minimum charting. Obviously he's not in health care. :)

It has gotten ridiculous that as the amount of paperwork has increased, our staffing has decreased and the acuity has gone way up. Something's gotta give somewhere, and some days I think it's going to be my sanity that goes bye-bye. I plan on being a fun psych pt when the time comes though.

[klone, MSN, RN]

An experienced nurse will be able to take care of BOTH the patient and the chart, and know what's important to chart, and what's redundant or irrelevant.

[windjmmr]

do nt forget the weekly psych notes either or the Abt notes.. but you know then they want to know why it isn t getting done either...we have to be out on time and they won t authorize OT..unless it s bad situation but it s okay for them to tell you you have to stay after being on your feet for a shift already and also you ve already been awake for the whole day..then they wonder why nurses are leaving the field..the sad part is in my building your raise depends on your evaluation..we do nt get an across the board raise like most places..so if you get a bad eval guess what..i ve seen CNA s get only a dime raise for the work that they do..but the front office crews well they get the bucks for staying under budget...another thing that i d like to see is that they mandate that all Ltc administrators have to be nurses. Then i think at least once a month anyone with a license that is in the front office area they need to do a rotation on the floor and not on 7-3 shift either to see what wedeal with and see if they can get done with what they mandated..(that would be fun to watch)

[mama_d, BSN, RN]

An experienced nurse will be able to take care of BOTH the patient and the chart, and know what's important to chart, and what's redundant or irrelevant.

Ah, but many places require redundant and irrelevant charting.

And I don't care how experienced you are, if you don't have shifts every once in a while where you just CAN'T take care of the pts safely and get the paperwork done, you're either skipping stuff that should be done or else you have dream staffing and all the rest of us want to come and work there too.

[klone, MSN, RN]

Sure, I think everyone has those shifts.

What I'm talking about is how there always seems to be a few nurses (and they're often the same ones) who have to stay 30-60 minutes past the end of their shift on a regular basis, in order to chart. Something's amiss if you're regularly behind on your charting.

[INLPN93]

An experienced nurse will be able to take care of BOTH the patient and the chart, and know what's important to chart, and what's redundant or irrelevant.

What keeps you employed as a licensened nurse is completing the *required* charting.

Its the 'experienced, knowledgeable' nursing management that P & P's redundant, irrelevant charting requiring the experienced on the floor nurse to do the ridiculous and redundant charting. The ones who do not actually work the floor dictate our charting guidelines. Can't imagine why its such a mess......

[nurse2033, MSN, RN]

I was just discussing this at work my last shift. Our evaluations include nearly everything except our clinical practice. Attendance, charting, appearance, customer service and so on are highly held by the corporate bean counters. Who notices when you perfectly titrate drips to keep an optimal BP or HR? My personal focus is on patient care and my charting comes second. I also agree with the poster who pointed out that charting something doesn't mean it was done. It all comes down to compliance with JCAHO rules. Without the JCAHO certification, we wouldn't be in business. I see it as a necessary evil.

[klone, MSN, RN]

When I said this:

know what's important to chart, and what's redundant or irrelevant.

I was referring to this quote:

The mantra we all learn in nursing school is, "If it isn't charted, it isn't done," an impossible rule to satisfy. Since what could be charted is infinite, I begin each shift feeling that I have already failed in my documentation.

That's true, what could be charted IS infinite. "Pt sipped water." "Pt is watching TV." "Pt is visiting with family."

But like I said, an experienced nurse will be able to know that a lot of stuff IS irrelevant and unnecessary to chart. Do I need to chart that "pt turned over in bed" on a healthy postpartum mom who will be going home after 24 hours? Of course not. Would I chart it on a geriatric patient who is at risk of pressure ulcers? You bet I would.

[mama_d, BSN, RN]

Sure, I think everyone has those shifts.

What I'm talking about is how there always seems to be a few nurses (and they're often the same ones) who have to stay 30-60 minutes past the end of their shift on a regular basis, in order to chart. Something's amiss if you're regularly behind on your charting.

Gotcha now...and I agree generally speaking. We have a couple of nurses on days who have been @ the hospital for 20+ years who STILL cannot get out within a reasonable time frame. They attribue it to their age...I attribute it to their poor time mgmt.