Charting every 2 hours?

Specialties Emergency

Published

Just thought I'd see if other ER nurses have to do this?

In our ER, nursing management wants us to put in an RN note every two hours about the status of the pt - even if there is no real change in status. Plus they want us to chart why we are giving a med (not just in the MAR) in the RN notes.

I understand charting the initial assessment and work-up, but really, every 2 hours, plus why we are giving a med? Management tells me that it's to protect me in the court of law just in case something goes wrong. But I'm like, I have to be out in the ER working up patients, helping other nurses, taking patients to CT - I can't chart on all of my patients every two hours. Am I being too resistant, or are they being unrealistic?

This is the only ER I've ever worked in, so I'm curious if this is standard practice or what?

Thanks,

C

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I think more charting proves that we are taking care of patients and sometimes means more money. Of course it's hard to take care of patients when we are charting everything. The higher-ups that make these decisions have NO ideal how much we do. :)

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Don't see it as necessarily practical in the ER, but had one employer in home health demand every two hour charting. Think the rationale in hh is because many don't bother to chart the minimum if they can help it.

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Specializes in med-surg, step-down, ICU/CCU, ED.

yep, pretty standard to chart on a pt q2h in the ER. Now whether it's actually done is debatable, some days it's much easier said than done.

As for charting why you gave a med, well that does not happen at my hospital. We chart the med given (including time, route, etc) but that's about it. Sounds like your typical nursing school BS work but I could be wrong.

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"typical nursing school BS work" sounds about right

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I guess it's just frustrating when management tries to put unrealistic demands on you when you know they couldn't do the same themselves - but that would be getting into a larger issue.

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Specializes in ER.

We have to chart q 1 hr for stable patients, q 15 minutes for traumas/criticals! And if there are patients in the waiting room waiting to come back, we have to chart on them too. I am very shocked that some hospitals don't even require q 2 hr charting!

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Specializes in Med-Surg, ER.

We have to chart every hour in the ER and are suppose to round q30 min.

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We have to chart every hour in the ER and are suppose to round q30 min.

This makes me laugh because when waiting in an ER bed one time, somebody finally got the idea to close the door to my room because I made eye contact with anyone who looked at me as they passed my room and didn't bother to come in. :lol2:

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I am not a nurse, however I have been required to chart every hour example when working hospice. I know charting is a pain in the neck, very redundant and it is very important. I am a CNA and with a easy to use computer program - touch screne where I work - it takes me 45 min to chart 10 patients over a 8 hour shift - which of coorifice I only get paid for and work 7 1/2 hours a day(I have a unpaid 30min lunch break). Both points rediculous.

However, Experience has taught me - You never know how important that one little thing is that you did not chart until you experience how important it is-the craziest complaints from the least expected. All patients and family members will file a lawsuite or make your life a living blank blank blank if you do not cover yourself, this is a business. I often feel charting takes my time away for me to do my job and it sometimes makes me feel as if I work in a world of betrayal - this is the world we live in. We choose our jobs and we choose who we want to be. We decide by fact also our charting - be honest.

I have discovered long term - passing information has been most benitficial for patients -because the health care team knows better what is going on and the patient the result is better care.

Yes is is a downer - I would rather take more of my time being good to my patients like bringing them a fresh cool glass of water vs charting. It is their choice also and ours - so don't get down on charting.

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Specializes in Clinicals in Med-Surg., OB, CCU, ICU.

Did they specify what they wished to be charted? It is not that you are not checking in on these patient on a regular basis, but the charting would not reflect this fact unless one charts. This may be driven from another source, not just the ER management would believe this is a good idea. I know ER doctors have a recording system and have their notes dictated. Hmmmmmmm.... maybe this service could be used by the nurses too---oh day-dreaming again!:lol2:

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Specializes in PICU, Pediatrics, Pediatric Home Health.

Although I am a relatively newer RN, every unit I have worked on and have floated to requires q2h charting. Even if there are no changes, I always chart "No changes in patient assessment. No signs of impending distress. No pain." or something similar. In the PICU I work on, although they only require q2h nurses notes, it requires q1h patient assessment charting.

I also work per-diem for a home health agency and they told me that for medicare reimbursements, they require q2h charting.

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