chartign question

[sweetieann]

So I'm at a facility that uses paper charting. As much as I'd like to be able to provide pt care AND chart right at a given moment, that's near impossible:icon_roll. Other disciplines also chart on our nursing progress note, so sometimes it's not handy anyway at a particular second. That being said, is something like this (this is what I have been doing) acceptable?:

time of charting: 11am-"Pt received PREN Tylenol 650 mg at 10am for c/o HA pain "6/10"; follow-up at one hour post admin showed relief from pain per pt report of "2/10" pain. To monitor"

??

Thanks so much!

[mianders, RN]

I have never heard of other departments charting on the nurses notes (hence the term nurses notes). We have a multidisiplinary form that the other depts use. Since your facility does it that way you don't have any choice but to do late entries. Your documentation sounds fine to me. Although, I would bring it up to the powers that be about getting a form for the other departments to use. It looks a lot better if you end up in a deposition or something if you don't have late charting.

[meandragonbrett]

Other disciplines should not be documenting on NURSING notes. Nursing should be the only ones using NURSING notes! Everybody else does their documentation in the progress notes.

[grammyr]

We use Interdisciplinary notes for other departments to chart if needed. If ancillary staff is charting about a test being done, we also have a patient education document that all departments are to chart that the patient has been educated about the test/procedure. I have had the urge to pop people's knuckles for trying to chart on my nurses notes.

[sweetieann]

thanks for the reply. I guess what my point is ,though, is:

What is your protocol for "Late Entry?" How does your facility define "Late Entry?" In nursing school, we are taught to chart right as the events are occurring, and if not, to put "Late Entry." With today's hectic floors, is anyone able to chart right as the events are occurring? I remember LOTS of shifts in which I made my first note 12 hours later at the end of my shift--so busy, I had NO TIME to chart, much less eat, drink, or pee. Do you make quick notes to yourself and then chart later? If so, are your entries then dubbed "Late Entries?"

[meandragonbrett]

When I am busy, as with a sick patient circling hte drain, I keep a running note on paper of everything that occurs such as "Bronch 2012, levo started at 5-2041, SCDL Cordis placed-2045, etc." and when I get a free moment I go back and chart. Only time I use late entry is when somebody else might have possibly gone and written something before I was able to sit for a second and write my notes......that was when I did paper charting. (does this make sense?)

Computerized charting is a different ball game as our software records what time you record the event, but you also have a box to type in the time that the event occured. Therefore you don't do late entries.

If I remember correctly, the correct way for a late entry is "01/29/08 1503.... Late Entry for 01/29/08 1400- Pain reassed 0/10. No verbalized c/o at this time."

[KatieBell]

The only concern I woul dhave is if that was the only place you charted the medication. Meds should be charted pretty much immediately after they are given, so that no helpful sould gives your patient a double dose of Antibiotics or worse. While this may not happen, it definitely can, especially if say, you get called off the floor with another patient, or happen to have micturition syncope in the bathroom and someone must assume care for your patients. Things like bathing I dont worry about, but stuff like medication, seems there should be somewhere to mark it off, like an MAR or something? (Sorry have not used paper notes in a long time...)

I once gave my patient 2 percocets, and was charting it, when my helpful colleague was sailing past me giving the same patient 2 more percocets... grrrrr.