Chart too much...

RNsRWe, ASN, RN · Aug 4, 2006

I work with a seasoned nurse who recently told me that from a legal standpoint the less you chart the better. God forbid, if you are called to court the more charting you do can actually get you into trouble. I dont see how. I mean I chart what is necessary...I dont write novels on my pts. Maybe cause I am still new? The seasoned nurse writes an opening and closing note. I do the same with any important events that occur thru shift. If nothing is going on..I will chart pt in bed sleeping..etc. Another seasoned nurse overheard this conversation and started laughing. She said, "You new grads put too much emphasis on charting. Its not as big a deal as you guys think." So tell me...what so you think. By the way, at my facility we chart be exception.

Well, charting (complete, concise and properly flowing) was a HUGE thing at our school....and I happen to believe a nurse who told me what a blessing it was that she DID chart well when there was a lawsuit and she had her notes to back her up. SHE didn't suffer any ill consequences from that issue, but the prior nurse(s) who didn't chart as she did sure had problems because of it.

JazzyRN · Aug 7, 2006

Trust me, charting as much as you can is very important. It wont seem important until something happens and it becomes an issue. There was an issue where a pt of mine died, the family believed it was a wrongful death and there would be a possible lawsuit. Then people scrutinize everything youve charted and your charting becomes your record of you doing your job well. I cant emphasize enough how important charting everything is, things you may not think are significant. I'm thankful my charting was in tiptop shape that shift. It may be annoying writing everything out but when it comes down to it, charting can really save you, when s**t hits the fan.

NurseyBaby'05, BSN, RN · Aug 7, 2006

I try to be very thorough in my charting. If something should come back to haunt me down the line, I'm counting on my notes to jog my memory. In five years, I'll have taken care of thousands of patients. I'm not going to remember every detail of every last one's care. The one's who's family members hem and haw about suing and you remember distinctly are usually not the ones who wind up suing. It's the nice, quiet ones who blend in with the woodwork. I'm all about covering my butt and you should be too.

rnsrgr8t · Aug 7, 2006

IMO, I have been a nurse for 8 years, and I believe charting is VERY important. My preceptor right out of school drilled that into my head, "If ya don't write it, ya didn't do it". She also drilled into me to document so I could read the chart 5 years later and know exactly what I did. If you ever have a patient that sues years later, you are not going to be able to remember the important details. We also chart by exception but I always include pertinent negatives (clear breath sounds, hear rate regular, well perfused etc). I commend you on your desire to want to chart correctly. Follow your own gut (it is your license) and chart how you feel appropriate. In my new job as a PNP, I have been frequently commended for my detailed documentation. Get into the habit now and it will serve you well in the future.

TinyNurse, RN · Aug 8, 2006

I was once told, that if you have time to chart, then you weren't actually in with your patient doing stuff...................sorta made since, but as I got further along in my career I knew this person's advice was wrong.

I've never been called to court, or to a deposition, but if I ever am, I want to be able to count on my charting to know what my patient looked like from hour to hour.

gitterbug · Aug 8, 2006

Remember we were taught if it is not written-it is not done. With the use of flow sheets, some of the usual things we had to chart are now covered, but it pays to CYB.

Tweety, BSN, RN · Aug 8, 2006

Charting can save your butt.

I've seen my charting in the possession of a lawyer before and was pleased that I had the facts, without fluff. You never know what is going to come back to haunt you.

Continue to chart events as they occur, what you did, how things look, feel and smell, and the patients response to care. Do however take a good look at fluff. I work with a nurse that writes useless things like "A&O x 3" when on the computer he checked neuro was WNL. Double charting information is a waste of time.

This nurse that told you the less charting the better is wrong. Stick to the facts. I think you can over chart, but making it a goal to underchart because you think that will save your butt in court is a grave mistake.

Trauma · Aug 8, 2006

I have a different viewpoint than most. Our flowsheet is organized to chart by exception only. If the lungs are clear, just put a check in the box. If they present fine scattered rhonchi upon auscultation, then put an asterix in the box and write that in the narrative section. If its not an exception, I dont chart it. I prefer to be in my rooms with my patients to take care of them and their families. My philosophy is that if you provide great care to them, then there will be no need for a lawsuit. After 9 yrs, so far so good.

I believe that charting vaguely can get you into trouble if called to give a deposition. For example, the nurse who charts "well perfused" how do you know, did you do blood flow studies to all organs and extremities? Sure, you and I know what they are talking about but a lawyer will eat that for lunch. You just have to be careful about what you chart and how you chart it.

I'm not saying my way is right or the other ways are wrong. This works for me and I am comfortable with it. You have to find your acceptable levelof charting.

Peace,

Troy

Tweety, BSN, RN · Aug 9, 2006

I have a different viewpoint than most. Our flowsheet is organized to chart by exception only. If the lungs are clear, just put a check in the box. Peace,
Troy

Actually, I think we have the same viewpoint. We chart by exception as well, which is why the due that writes "Lungs clear, A&O x 3" is wasting his time.

There are things that happen throughout the day that are exceptions, such as pain control issues, wounds, and patient changes, etc. that are best covered with thorough charting, rather than by exception.

DutchgirlRN, ASN, RN · Aug 9, 2006

The only things I chart other than my initial assessment are PRN's and their level of relief. If a surgical patient has walked in the hall and how tolerated. If the patient leaves the floor to smoke, if the patient is confused, etc. Only things out of the ordinary. I never simply chart patient sleeping, that is too much info that can hang you in court. Sleeping is an expected activity in a hospital. Chart exceptions only.

leeae85 · Aug 9, 2006

speaking of all this charting, besides just sittting and looking through old charts, are there any good resources out there that can help me out with my charting? I just graduated in July, (from a PN program), and charting was very important, but i still dont feel comfortable with it, is it something that will come with time?

thanx!