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Charting has to be done no matter what?

Posted

Most of the nurses at my job do their daily required charting each day. However, we have a few nurses who don't do their daily required charting. Management is now telling us that all charting has to be done period. For example, if the other shifts did not do their required charting then they want someone from another shift to do that person's charting for them. For example, the 7-3 nurse did not do some required charting on her shift. So the supervisor tells the 3-11 shift nurse to do the 7-3 nurses required charting. Is this something new or do all LTC facilities do this now?

NutmeggeRN, BSN

Specializes in kids. Has 25 years experience.

No way am I charting for anyone else. EVER.

Nascar nurse, ASN, RN

Specializes in LTC & Hospice. Has 35 years experience.

I wonder if you are misunderstanding your DON.

Things such as medicare charting needs to be done daily but there is no requirement as to what shift it needs done on. Therefore if days doesn't get to it, technically there is no reason an evening nurse can't do an assessment and then document for the required medicare charting. This DOES NOT MEAN your charting someone else's assessment.

Now with that said, we all have bad shifts and need a hand, BUT if it's always the same person not getting done (and probably the same one dilly dallying all day) then I wouldn't be volunteering to bail them out either. management needs to step in and get them to do their job.

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

There must be a skilled note at least once a day after the first 72 hours. If the day shift didn't document, the 3-11 shift should. Document what YOU did, what YOU saw. Not what happened on another shift.

CCU BSN RN

Specializes in CICU, Telemetry. Has 7 years experience.

Like others have said, there's a difference between telling you you have to chart a set of vitals for 1pm when you weren't even clocked in and definitely didn't do it,

and saying that if q24 hour charting isn't done on days (e.g. assessment, bradens, falls risk, whatever) it becomes your responsibility.

The former would be wrong, the latter is encouraging you to talk to your co-workers or your supervisor if you notice a trend with one person. Essentially, someone needs to rat out the lazy people, and no one was doing it. The boss is appealing to the uptight, rule following employees by telling them that their paperwork will be double until they rat out their co-workers. Effective management, I'd say.

Yeah, that's right, leave all charting for night shift. They don't do anything anyway. That's what I see here.

Edited by caliotter3
Clarification

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

Since patients should be sleeping on 11-7 it would be difficult to assess them in order to write a note. Split the work between days and evenings

FurBabyMom, MSN, RN

Has 8 years experience.

Um...chart things that other people did and didn't chart? No way. Not unless I'm in a situation where one nurse is charting but others are helping manage a patient (like a code or other emergency). I have to do something or see it happen to chart it.

Are they talking about things that need done sometime every 24 hours? Like care plans, etc? Cause if it can be done anytime but should be done on days, then yeah, sure, if I have time to do so I will do it. I'd totally do that. Many times on my old unit, I didn't get to my care plans or my coworkers on days didn't. We just had to have one entry each day, so we did the ones that needed done for the day and then the ones our shift was responsible for. Like days did odd numbered rooms, nights did evens. If the days nurse I relieved didn't get to it, I'd take two minutes and fill it out. Something like that...no problem.

Straight No Chaser, ASN, LPN

Specializes in Sub-Acute & Long-Term Care Nursing. Has 5 years experience.

They probably want you to chart on the patient because the 7-3 nurse didn't so they've been charted on that day. (Medicare rule)

I doubt they are asking you to chart on behalf of the 7-3 nurses, and if they are you need to RUN away.

Natasha, CNA, LVN

Specializes in Psych. Has 1 years experience.

If a lawsuit happens...what evidence do you have?

ruby_jane, BSN, RN

Specializes in ICU/community health/school nursing. Has 12 years experience.

I can only chart on what I see, hear, and do. Maybe if, in verbal report, previous nurse stated that vitals were WNL, I *might* chart as such but would be really tempted to do a reassessment to make sure since I did not have any starting data. This sounds unfair to the night folks but it's also catastrophically bad for a nurse's license if s/he doesn't chart.

KeeperOfTheIceRN, ADN

Has 4 years experience.

Perhaps your DON needs to implement some consequences for those who are not charting. It does not become YOUR responsibility to cover another nurse's laziness, refusal, poor time management, etc. etc. that is contributing to them not charting. No way will you EVER catch me charting for someone else. NOPE.

Meriwhen, ASN, BSN, RN

Specializes in Psych ICU, addictions.

The ONLY way I would chart something for another nurse is if it was made specifically clear that these were not my observations/findings, but another nurse's, (e.g., "per previous shift RN, ...", or "per staff report, ..."). And that would only be if that information happened to be very pertinent to what was going on during MY shift.

Otherwise, no way in hell.

TitaniumPlates

Specializes in ED. Has 15 years experience.

So true story.

I received an email from the "documentation committee" (5 RNs who do nothing in our short staffed unit but pore over our charts to find things on their co-workers. gleefully. but somehow their own charts never get pulled for review...) about a pain re-assessment that I somehow forgot to do with my 5:1 Level 1 trauma load--2 criticals and 3 beds that flipped ridiculously fast.

Email reads: Titanium, on pt XYZ four days ago, you forgot to do a pain reassessment after you administered 650mg of tylenol. Please go back and put that in, and when you are done, please email me to assure me that this has indeed been taken care of.

I wrote back: Dear Chart Police (didn't really say that but felt like it). First, I have zero recollection of this patient from 4 days ago. What their pain reassessment was from their life saving Tylenol admin, because I was busy with my intubated crushed skull kid and my refractory SVT old lady. sorry I wasn't that attentive to XYZ who was here for 45 minutes. Second, I did go back into EPIC just to see if I could even add anything to that chart at this point, and amazingly, you can't do stuff like that 4 days after the event. Imagine my surprise.

So, chart person, how would you like me to falsify the record at this point? Please email me with a detailed explanation on how or why I would ever chart something that I probably did not even do?

Suffice it to say, I did not receive an answer. Lemme tell you....this crap about "have you ever had to justify yourself in court over a chart entry????" HUH? HUH?HUH??????? Is just that. Crap. I haven't met one person in my unit that's been called into court over anything. At all. I knew RNs that their charting was LITERALLY....pt arrived. they're breathing. gave this med (sometimes scanned, but mostly overridden). pt left.

And nobody did a damn thing. I've taken over pts that have 2-3 lines, a chest tube and a foley...and not one thing is documented. Do I do that myself? NO. It's bad business. But is this the be-all and end-all of your nursing shift? If you are one of the unfortunate ones who are on a unit that has a micro-manager, I'd say start looking quietly for another job. I think that if you chart in a reasonable manner, then you are fine.

Management uses "court" as a scare tactic. Management follows the law when it's convenient for them...when it's gonna cost them money in the end if you don't tighten it up. Do your best, follow the policies of your hospital/facility to the best of your ability and to hell with anybody else's charting. That's on them. Believe me when I tell you, no matter how well you chart, it will never be good enough for management. They want all of your time accounted for---since you know....all we do is sit around and eat pizza while perusing facebook.

djh123

Specializes in LTC, Rehab. Has 5 years experience.

That is insane. How can a nurse on a later shift describe exactly what happened on a previous shift? I don't even always do MY required charting, much less another shift's. I do as much as I can every day, but if it's already 30-45-60 minutes after the end of my shift and I still haven't charted on every person I'm supposed to chart on every day (not to mention those who I need to chart on because something happened, whether they're one of my 'must-chart-on' ones or not), I sometimes just have to leave regardless, you know?

Yes, I am wondering why management is not stepping in and getting these nurses to do their own job. I can barely get my own charting done and then I am expected to do someone else's charting too?

You can't win. They say you have to do your required charting. Of course, if you have to do "overtime" in order to finish all of your required charting then you are "the bad guy" for having overtime.

nurseburst, ASN, BSN

Specializes in Telemetry, Step-Down, Med-Surg, LTC.

Hahaha. I am seeing this more and more, not to mention being asked to go do documentation like 10 - 20 days back... Are you kidding me?