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.
Information given in our last staff meeting says that we have to work harder on the Courtesy part of our patient care. Knock on doors, keep curtain closed, find out what name the patient likes to be addressed by, blah, blah, blah......oh, and "the hospital will get paid on how these survey scores go." WHAT? Never mind actual patient care, I guess.
Next time I'm in a hotel, I think I'll try NOT paying because the staff didn't find out how I'd like them to address me.
Specializes in Nurse Leader specializing in Labor & Delivery.
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.
Yes, I agree. And in my OP, I had originally wrote "a GOOD nurse..." and then changed it to "experienced" because I figured I'd take a lot of heat from people.
Yes, I know lots of nurses, newer and with lots of experience, who have really poor time management skills.
In my eyes there are two kinds of documentation....one type is required to keep your job and the other is required to keep your license. I will not leave until the latter is completed. The former I am more than happy to complete if time allows.
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)
Give them 3-11.. with 3 CNAs, 2 admissions, stack of MD orders left from 7-3, hallway with heaviest medpass and a treatments galore on everybody with the tiniest wound.
Give them 3-11.. with 3 CNAs, 2 admissions, stack of MD orders left from 7-3, hallway with heaviest medpass and a treatments galore on everybody with the tiniest wound.
Don't forget 35 residents with at least 20 on medicare charting and at least 1 fall and 1 skin tear. Don't forget the :confused: 20 minute tirade by someone's daughter who hasn't been to see "momma" in 6months to a year, but doesn't understand her change in condition at 90+ years.
So yes, I stay over and chart it all, because I Cover my a** and my license and by the way I am also covering the facility.
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.
That does'nt mean it won't take her 2 hours of overtime after a hellacious shift. What's "redundant" is not important to CNO's and managers, never mind JCAHO who just want to see boxes checked off.
Your post is either totally insensitive, or else you still do paper charting.
The "If it was charted in didn't happen" mantra is impressively pervasive considering it's false as far as many nurses interpret it.
Thankfully, "Meaningful Use" legal requirements will do away with most of our redundant and irrelevant charting, it's about time.
Not quite sure I understand your point, but I am aware that "If it was not charted, it was not done" is the legal standard for nursing conduct in most if not all the 50 states. No interpretation needed, THAT's what you WILL be up against in a court of law.
Charting is kind of a pain in the butt, no question. I know the 'fill in the blank' assessment so well now I can write one up in about 5 minutes, about a minute for fall risk assessment, 1 for interventions, and the progress note can take anywhere from 5-20 minutes depending. It's all very formulaic where I am, we do those PGIE notes, ie:
P: Pt is in pain
G: Pt is out of pain
I: Fully assessed pain. Administered xyz drug as ordered as requested. reassessed for efficacy. Promoted comfort by xyz
E: Pt reports pain lessened. Will continue care.
It seems silly most of the time, excepting those pts who something ACTUALLY happened with, ie "BP dropped to 80/40, talked to MD x and requested xyz, obtained xyz, reassessed, BP inc to 120/70". My biggest issue is that we don't chart in the same system as the MDs and everyone else, so no one really looks at our notes except maybe in the case of a law suit or if we're being audited. And like someone else said, just because it's charted doesn't mean it's actually done. Also, at my hospital we have to assess Braden risk every shift, which is sort of silly because the a whole lot of people's numbers aren't really relevant (for example, someone being bedbound for 1-2 days isn't really a huge increase in pressure ulcer risk in most cases, it's more a long-term thing), but hey, whatever gives us petty fodder to criticize each other.. :)
Also, yeah, I do see the nurses who every day are there 2-3 hrs past there shift. MAYBE sometimes, but on a regular basis, something is wrong. Just my
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.
I find it incredible to believe that you just wrote that. no two situations are the same.
it ridiculous somedays...we have MDS charting.bi weekly psych notes and a monthly notefor the same ...daily abt incident cahrting readmission charting and then you have the incidental charting ..you also have to chart all interventions before you give a prn med to boot.. couple that with the problematic families that you ahve to deal with due to the fact that the front office crews make all of these "interevntions' that you have to doccument on not to mention dealing with some CNAs who you have to watch that they don t hide...then you have to get a med pass out stop in the middle of the med pass to feed patients then finish it..then a tx pass and if you are lucky enuf you have to do incident reports for anything that is found and in our building it can be up to 7 pages of paper work involved..and to boot it you have to be out on time as they will not approve the OT if you stay to finish ...if you stay they will write you up for it..then they wonder why nurses are becoming soured..then you have to hope that theer is no call out for the next shift or they will try to make you stay as well..where are our rights as caregivers when it comes to the safety factor for the caregivers? ( overtired staff)
Not quite sure I understand your point, but I am aware that "If it was not charted, it was not done" is the legal standard for nursing conduct in most if not all the 50 states. No interpretation needed, THAT's what you WILL be up against in a court of law.
The legal standard is that you chart to your facility requirements. Charting by exception is fully supported by legal precedent. Where nurses get in trouble is not charting to their facility standard, or inconsistently charting beyond what is required.
We went to a charting system a few years ago that is a quasi charting-by-exception system and brought in surveyors from CMS and JCAHO, a medical malpractice lawyer and a Legal Nurse Consultant. Even with their blessing we had a lot of pushback from Nurses who felt the need to chart excessively for the purpose of CYA.
Take for instance an IV start. There are approx 40-50 individual steps in starting an IV depending on the source you refer to. Should you have to chart to each of those steps individually? Or should you just chart the location, guage, anesthetic used, and ongoing assessment of the site (information that may be useful in the care of the patient).
I have never charted that a patient's head is still attached to their neck, does that mean I never noticed their head was still attached to their neck?
Defensive medicine, which includes useless Nurse charting, negatively affects patient care. Because of this, IHI and CMS included "Meaningful Use" requirements in the HiTECH act. Except for small clinics and Hospitals, Electronic charting will be required, and all EMR systems will be required to be certified based on Meaningful use requirements, which essentially gets rid of all charting that doesn't serve a purpose in supporting decision making in the care of patients.
I think we all work with Nurses who focus more on the chart than the patient to at least some degree or another. I've gotten report from many nurses who don't really know why the patient is here, but every mundane aspect of generic standards of care is charted on in at least two different places and to the nth degree, but they don't see the bigger picture for this particular patient. I give them credit for being thorough, but I think we could do our job better if all that effort was directed at the patient rather than populating a spreadsheet.
:confused: 20 minute tirade by someone's daughter who hasn't been to see "momma" in 6months to a year, but doesn't understand her change in condition at 90+ years.
tntrn, ASN, RN
1,340 Posts
Information given in our last staff meeting says that we have to work harder on the Courtesy part of our patient care. Knock on doors, keep curtain closed, find out what name the patient likes to be addressed by, blah, blah, blah......oh, and "the hospital will get paid on how these survey scores go." WHAT? Never mind actual patient care, I guess.
Next time I'm in a hotel, I think I'll try NOT paying because the staff didn't find out how I'd like them to address me.
I am so ready to walk away from this....