Charting/Documentation

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Specializes in Ambulatory Care/Community Health.

I need advice on how to handle a situation. My immediate supervisor- the practice manager at an ambulatory care clinic (who has NO medical experience whatsoever) has told me that she feels that I spend too much time charting/documenting. Honestly, I feel that I chart only the basics, and document only what needs to be documented. Most days, I have so much to do, I don't even get a chance to document the basics that I really should be documenting. If I stay even 1 minute past when my shift ends, she yells at me. I'm not sure what to say or how to say it. Any suggestions?

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What does she expect. We have to chart every single thing we do to protect ourselves.

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Tell her to back off...it's YOU and YOUR license that is on the line. You worked too hard to get it so don't let someone push you around. Maybe try to figure out how to manage your time a little bit better so you don't stay late.

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Tell her to back off...it's YOU and YOUR license that is on the line. You worked too hard to get it so don't let someone push you around. Maybe try to figure out how to manage your time a little bit better so you don't stay late.

Why do we always assume its about bad time management? Sometimes it's just been that kinda day and there is no time

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It may be that she doesn't understand how important it is to document. You can always try to sit down with her and explain why it is important to document. It may not change her opinion, but at least you tried.

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Specializes in Sub Acute and Wound Care.

I am a Nurse manager of a large ambulatory clinic. As a nurse I know documentation is so important, and I often encourage my staff to chart more...Before I can respond to this post though I need to know the following: 1. How many patients do you see each day vs how many hours are you scheduled? 2. How many RNs are there. 3. What type of documentation are you doing? Paper/EMR. 4. Do you feel well trained on that type of documentation. 5. Do you have any suggestions to improve the documentation process to help you chart more efficiently? 6. Are you the only one who is being called out about overtime etc?

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Specializes in Ambulatory Care/Community Health.

Hi CarreBarreLPN,

Typically, I was seeing about 16-20 clients per day in-office for "nursing visits", plus giving about 10-20 injections (immunizations) per day (to patients who were seeing Dr.'s), plus answering/triaging about 20-30 patient phone calls per day. I am scheduled 8 hrs. per day. Nurse visits are booked as 15 minutes each. I was the only RN, with 1 LPN. Thankfully, we just got another RN. We use an EMR system, and yes, I feel well trained on our system. If there were drop-down boxes for documenting nursing dx.'s and interventions, that would be extremely helpful. I have mentioned this before, but have recieved no feedback. And, no, I'm not the only one who is called out for not being able to leave on time, there is one MA who is also finding it difficult on a regular basis to complete all tasks on time. On top of what I mentioned above, there are also walk-ins, and "tasks" assigned by Dr.'s (mostly calling pt.'s about labwork, or calling to get more information about symptoms). I LOVE my job, but some days are just so overwhelming, it makes my head spin! :)

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I have worked in ASC for 13 years. I came from a hospital ICU where you charted everything and at the ASC we charted by exception only. We have done a huge turn around where we document every nitty gritty detail. We devised a check system and are able to complete charting immediately. When the patient is discharged we complete the IV and sign out the time. We are done. The system took a lot of work. We planned it like an EMR but on paper. Now, the charting is so detailed for the Post Op, that we do check the charts at the end of the shift to see little details are complete. But we have NO overtime related to charting. Our ASC would not tolerate it.

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Specializes in Med/surg/peds/womens.

I hope you get paid a lot of money for doing your job. WOW, you have a lot of work for 1 RN. My clinic sees around 90 patients/day. We have an EMR system which we review the patients allergies, medications, chief reason they are being seen etc. and can also document a note. We can order labs etc. if needed to do in the office. We do give injections also. We have a triage nurse who gets many calls throughout the day. We are also expected to leave in a timely fashion. We have several RN's, LPN's and MA's. We take turns leaving early as the day is ending. Several of the nurses can work in all the areas, so we cover if the MD or NP would need something at the end of the day. Some days are very hectic and on occasion we do stay later. :laugh:

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