Published
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
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.
As if. I have 14 clicks when charting on an indwelling IV.
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.
You are right in theory, but wrong in reality. Every hospital has policies about pt.s transferring from ICU to tele, right. One gives a thorough telephone report, and the pt. goes upstairs on monitor, with a RN in attendance. Simple, no?
Go research the NSO website. There is a case study there dealing with this exact scenario. The pt. crashed not long after transfer, and the transferring nurse was sued BECAUSE all those hospital policies were not SPECIFICALLY deliniated in her charting as being carried out.
When we went to computer charting, it was meant to be by exception as well, yet 2 years in we are told not enough nursing notes are being written. WHY? Lawsuits.
Breadth of charting and nursing competence have no relation to each other. But I DO agree, we spend WAAAY too much time on documentation, when we should be teaching ,listening, comforting and assessing our pt.s.
Blame technology, blame idiotic federal egulations (thank you George W. Bush), blame your CEO's that just want quick data retrieval. They make the rules, but not one of them knows our job.
We have a doc who show up right at shift change every morning, grabs all his patients' charts, and keeps them until he has gone through every single one. All this time we are trying to get our chart checks done. Depending on how many patients he has on a particular morning, the night shift regularly has to stick around sitting on our thumbs for 30 to 90 minutes waiting on his royal highness to graciously point to the pile and say "you may have them now."
The DON has talked to him about this situation but he doesn't care. So tell me, how is this poor time management on our part?
You are right in theory, but wrong in reality. Every hospital has policies about pt.s transferring from ICU to tele, right. One gives a thorough telephone report, and the pt. goes upstairs on monitor, with a RN in attendance. Simple, no?Go research the NSO website. There is a case study there dealing with this exact scenario. The pt. crashed not long after transfer, and the transferring nurse was sued BECAUSE all those hospital policies were not SPECIFICALLY deliniated in her charting as being carried out.
When we went to computer charting, it was meant to be by exception as well, yet 2 years in we are told not enough nursing notes are being written. WHY? Lawsuits.
Breadth of charting and nursing competence have no relation to each other. But I DO agree, we spend WAAAY too much time on documentation, when we should be teaching ,listening, comforting and assessing our pt.s.
Blame technology, blame idiotic federal egulations (thank you George W. Bush), blame your CEO's that just want quick data retrieval. They make the rules, but not one of them knows our job.
I'm familiar with the NSO case studies but that example doesn't sound familiar, which one are you referring to?
The only way i could handle all that charting for 16 years in med-surg tele was to go into the room, do a cursory assessment-- listen to lungs the way most MDs do--fast, and hell no, not every freaking lobe, check ankles for edema, listen to see if heart rate is irregular, assess for pain, listen to bowel sounds, check the catheter and iv site, colostomy-- whatever attachments and accoutrements they have, and carefully assess what the off-going nurse told me in report-- dealing with the major problem of the day or the reason pt is in the hospital; then get the heck out and chart your assessment as quickly as possible. I was very grateful the years i was in charge.
I think many nurses do not realise that staying back is a part of nursing, when they enter nursing school.
I ALWAYS chart only exactly what I need to. There is no point in writing reams of notes that, frankly, no-one is going to read as they do not have time. You have to be short, sweet and succint - to the point in other words. I will stay back 20+ minutes to do my charting after handover, but no more than that. Nobody needs long nursing notes to read, unless something untoward happens, ie: patient fell, give basics of what happened, who witnessed it/was involved, incident report done, time/s, date, etc. I hand over everything else that has happened and isn't worth charting.
You have to be quite choosy with what you chart.
And to the poster who stays back 2 hours to chart, you really need to try and claim for that. Anything over 30 minutes if I need to stay back, I march down to the shift NMs office, and claim the extra.
As long as you legally cover yourself charting, you will be OK.
I don't mind however staying back the odd 15-20 minutes, cos trying to claim it is too much bother - especially on late shifts when u just wanna get home!
I think many nurses do not realise that staying back is a part of nursing, when they enter nursing school.I ALWAYS chart only exactly what I need to. There is no point in writing reams of notes that, frankly, no-one is going to read as they do not have time. You have to be short, sweet and succint - to the point in other words. I will stay back 20+ minutes to do my charting after handover, but no more than that. Nobody needs long nursing notes to read, unless something untoward happens, ie: patient fell, give basics of what happened, who witnessed it/was involved, incident report done, time/s, date, etc. I hand over everything else that has happened and isn't worth charting.
You have to be quite choosy with what you chart.
And to the poster who stays back 2 hours to chart, you really need to try and claim for that. Anything over 30 minutes if I need to stay back, I march down to the shift NMs office, and claim the extra.
As long as you legally cover yourself charting, you will be OK.
I don't mind however staying back the odd 15-20 minutes, cos trying to claim it is too much bother - especially on late shifts when u just wanna get home!
Absolutely, you have to be choosy about what you chart, and this like all other nursing skills is learnt by experience.
2 hours OT for charting should have meant that the nurse in question had a HORRENDOUS day, and clearly not the norm. But if I have to stay 12 minutes over my shift, guess what, I claim it. NOBODY else in that place works for free, why should I?
It being "too much bother" is simply code for "Your hospital has set you up to annoy/shame you into giving them your skills for free".
Wake up and smell the coffee, folks.
tntrn, ASN, RN
1,340 Posts
I have been deposed twice for OB cases. In both instances, had I NOT charted as thoroughly as I did, I'd probably still be there, answering questions from the other attorney.