Chart Audits....you have to be kidding me!!!!!

Nurses General Nursing

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Ok......I just got a call from the night charge nurse. She audits the restraint charting somewhere around 2000hrs. She called to tell me that I didn't check the box (in EPIC) that states I notified the family regarding the restraints. Every other bleepin' box was checked except that one..........she called me to tell me that I had missed that one box. FYI.....this lady was maxed on pressors, rapid Afib, intubated and lined today and started in CRRT....wasn't like I was sitting on butt all day.

She apparently will call you up to 2 times and on the 3rd time if your restraint documentation isn't perfect........you have to come back in to fix it. I work 12 and half hr shifts. Some staff members have been called as late as 2200hrs. Can this even be legal???? I feel totally harassed. I was always under the impression that my documentation was mine....done under my license. If I failed to complete everything, than it was my license at risk and that it would also show up on my evaluation.

Can management really call you for such small infractions?

I regularly review charts for legal purposes in my work. You'd better believe they take those little boxes seriously. Nuff said on that.

Now, if we can make a good case for increasing staffing such that everyone working has time to use an hour or more out of every shift to complete the work which includes charting to standard, I am totally behind it.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Sigh.......not everything that annoys you is illegal. Compliance is huge and the documentation of compliance is huge. Lawsuits are frequent and can be devastating to the nurse.

Lets say this familiy sues for unlawful restraint and your documentation doesn't reflect proper adherence to the Policy and procedure and standard of care....are you prepared to pay up and possibly lose your license?

I would check with you malpractice carrier about restraint documentation and how important it is......

If annoyance helps with compliance...as long as it is equally applied it is perfectly legal.

A way to avoid going back to work for comply with incomplete charting....be sure your documentation is complete.

I know you are just REALLY ANNOYED right now....i get that....and yes the delivery of the message means everything...but your manager/charge nurse are answering to their boss as well.....it all trickles together.

Specializes in Emergency & Trauma/Adult ICU.
There are two camps of people........one camp that can admit how ridiculous this all is and the other that seems to believe that has some sort of deep level of importance.

You know, I probably agree with you on that point.

There are nurses who have been around long enough to see the possible consequences of review of care provided to a specific patient on a specific day ... long after the actual events have transpired.

And there are those whose limited experience does not allow them to see beyond the moment.

Specializes in Hospital Education Coordinator.

There are huge fines to the hospital if documentation regarding restraints is incomplete. To be correct, it has to be complete.

Remember if you didnt document you didnt do it!

You should be happy somebody is auditing the charts and calling you to remind you to do it!

You will feel a lot worse if in a few years time you get called to a court room because the patient or family decided to sue because you didnt inform them about the restraints.

^This!!!

You'd be surprised at how many lawsuits are settled in favor of plaintiffs based upon poor charting by nurses. Just be thankful that someone has your back.

Specializes in Public Health, L&D, NICU.

I understand what the OP is getting at. TJC and risk management have gotten so out of hand that we spend way, way more time caring for the chart than we do the patient. Yes, yes, I know, not charted, not done. But I also remember the days where you charted something ONCE and it was done. Now it has to be charted here, there, and then a third spot to really convince people that you did it. Actually, I'm not even sure that's it, I think it's that you document just to be documenting. Paper pushers in health care love nothing more than coming up with a new piece of documentation to add to the already huge pile. After all, what else is the nurse really doing? One more piece of paper won't matter. Except it's not one more, it's scores more, and it prevents good care in some cases because the nurse spends so much time just on it.

I also absolutely get OPs irritation about being called at home. Do you need to know something that only I can answer, and it can't wait? Sure, call me at home. Otherwise, save it for an email, or tell me when I get there in the morning.

And the irritation about delivery? I totally get that, too. When I'm being scolded because a patient complained that I "let" her vein roll, I could take it a lot better if the scolder gave it with the attitude of "I hate to even bring this up, but I have to" rather than "You suck!"

Thanks Monkeybug!!!!!

It can wait until you're next at work. After all, the family can't get the medical record to sue you for missing that box until the patient is discharged. (And really, getting sued for failing to notify the family? REALLY? You don't have a lawsuit unless there were damages, and Billy Bob not being immediately told Mom got restraints put on is not enough damages to get a lawyer to take the case on a contingency fee.) Unless TJC has walked into the building (and I'd argue even THAT isn't enough of a reason to demand I come back to the building immediately), IT CAN WAIT.

Specializes in Critical Care.

This is a pet peeve that I normally ignore, but it is relevant to this discussion; Not completing restraint charting is not a failure to meet the Standard of Care. The Standard of Care is a narrowly defined legal term, although we muddle it by using it inappropriately, such as to describe best practice recommendations. But as a legal term, which in this context is an important clarification, incomplete restraint charting is not a failure to meet the standard of care.

Specializes in Critical Care.

Part of my job includes outcomes and compliance for an ICU and ED, which means lots of restraint charting auditing on vented patients. Our compliance with complete restraint charting in the ICU typically runs 65-75%, which I find concerningly high.

Some other posts seem to imply that 100% compliance with this equals good Nursing, and I have faith that's not what they meant.

Nursing workloads are continuously becoming more saturated with high priority items, and it's sort of disturbing what is falling off our "to-do" lists, including appropriate checking of orders, bathing patients at risk for infection, swabbing caps, oral care on intubated patients, turning patients, etc. The fact tasks which have been well established to prevent more harm to the patient and provide more benefit to the patient aren't being done in favor of tasks which should prioritize well below these other tasks is what's concerning.

I don't consider it to be good Nursing to take time away from higher priority tasks in order to cover for a facility's poor staffing and workload management practices, in fact I consider that to be traitorous to basic Nursing principles.

This does mean facilities will have to suffer the consequences for poor staffing and workload management, which is how it should be, but we by no means should be impairing our ability to provide proper care and prioritization or to put patients at risk of adverse events.

This does mean facilities will have to suffer the consequences for poor staffing and workload management, which is how it should be, but we by no means should be impairing our ability to provide proper care and prioritization or to put patients at risk of adverse events.

Agree. Facilities should suffer the consequences. Not the patients.

Everyone has lovely suggestions for self-auditing and the like. Which task should OP have skipped to do that? What was less important than checking a box?

It's like all those times management gives us one more thing to do, "It will just take a few minutes." Those "just a few minutes" add up when new ones are added every week.

Specializes in Critical Care.
Agree. Facilities should suffer the consequences. Not the patients.

Everyone has lovely suggestions for self-auditing and the like. Which task should OP have skipped to do that? What was less important than checking a box?

It's like all those times management gives us one more thing to do, "It will just take a few minutes." Those "just a few minutes" add up when new ones are added every week.

Yes I despise the "it just takes a few minutes" excuse when adding more and more tasks while simultaneously cutting the hours that are getting those tasks done. My entire shift is filled with nothing more than things that "take just a few minutes", yet I leave arguably important things undone despite staying 45 minutes over and not taking my break. They seem to like to round down, making it seem as though 1000 three minute tasks is actually 1000 zero minute tasks, so we should be able to do those 1000 tasks and still have 12 hours to spare.

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