Chart too much...

[RN2B07]

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.

[admorn03]

As we were taught in nursing school, if it's not documented then it wasn't done.

Document, Document, Document. :typing

[sweetspirit]

I always tell others: "It's my A** on the line, not theirs" - I want to know who, what, when, where, and why!!!

[classicdame, MSN, EdD]

I learned the value of adequate charting when I started auditing charts. If the chart could not tell me the story, then something was missing and that only leads to questions and poking around for "problems". Charting by exception still requires you to chart. Remember, you are charting for YOUR attorney in case there is a question in the future. Your atty wants to be able to smile and say "see, here it is".

[oshkosh76022]

You chart your assessment, interventions, and response to anything abnormal or anything you intervened on. Pain, wounds, etc. I have been told also by other nurses not to chart so much, but when the Texas Board of Health came to investigate a blood reaction on a pt. they said my charting saved that hospital, and no you don't chart that a patient was sleeping because how do you know that pt. was really asleep..YOU DONT! I chart pt. resting in bed with eyes closed, respirations are even and unlabored, side rails up x2, call light in reach, bed low.

[anapoo]

Ok i havea question on this topic also.

I have recently went to third shift from second. I look in on my patients every hour, do i need to chart every hour even though they are resting???? And as far as times go, when you have six patients and you are doing things for all of them, what do you do about the time you write down. You can't be exact, or are you?

Say we get there and get report at 7 then i check my labs, then do my assessments, do start my charting at 7...assessment complete etc....?

No one has ever explained this to me and i hope i'm not screwing up all my charting lol.

[MIcrunchyRN]

I work in a facility where charting (Like assessments) is done by exception. There is guidlines for what goes into each area... if you chart something that is within the guidlines as normal and its not a problem area its assumed you ONLY assessed what you charted. Therefore in that case less is more. Because a simple check in the box means all that criteria is normal. Only time your supposed to chart is for problems or deviations of the norm.

clear as mud?

[suanna]

We have heard for years "if it wasn't charted, it wasn't done". Subsequently If it wasn't charted , you can't be blamed for doing it wrong. I chart a lot but I try to keep it to just the basic facts. The less embelishment you provide, the less your charting is open to misinterpretation by our friends in the malpractice courts. Discriptive narritive charting is always just asking for trouble, VS, LOC, who was notified and of what, are essentials but NEVER explain your problem solving process or interpretive thoughts in a nursing note.

[Daytonite, BSN, RN]

i had a patient climb over the side rails during shift report, fall and break both hips early in my career. i charted a page and a half including a picture i drew of how i found her because i was having difficulty describing it. i never heard from anyone about it. i hope that my charting was why.

i chose nursing law seminars for a number of my ce requirements and the leader of every one of them advised charting thoroughly on important and unexpected events. one seminar leader had a video tape of a deposition of a nurse who was being questioned about things she had failed to chart and it was stressful just watching her being grilled by the lawyer who was being nice, but you knew the nurse had goofed up badly. she said she had done the things but she never charted them. they had blown up posters of her charting.

from these seminars i learned that you never assume anything. get things down in writing and assume that the next person reading it might be a lawyer or a juror. these new charting by exception forms are meant to be time savers but i believe that they can also be trouble when something goes wrong. it only takes one patient filing a complaint one time to change your life.

the nurses who have been involved in lawsuits filed by patients. . .where are they? i hear about them, worked with a couple, and then these nurses seem to fade away. do they get disillusioned and leave the profession? don't know. i can tell you this, if a patient files a lawsuit against the hospital all the nurses involved with whatever care the patient is suing over are going to be interviewed by the hospital lawyers. they must do this on their own time and cooperate with the lawyers who will decide if their testimony will ever be needed if the case goes to trial. if their charting was below par, it will figure in on how the case gets settled. something i learned from being in management and now him is how many people read what we chart. and, long after the patient has been discharged people do go looking for specific information about incidents in narrative notes.

if nurses don't chart things and the hospital ends up in trouble, you are only painting a target on your back as not being a thorough practitioner. believe me, the bosses will know who you are.

[bluekermode]

Hi Dutchgirl RN

I chart by exception too, but I do chart patient sleeping on q hourly checks so if something did develop it's covered that I was in there checking resps, type of sleep etc.. but thats just my thing, I agree with covering my butt. Thanks.