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?
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.
Maybe they were trying to protect you from the chaotic ER.
Maybe a bloody trauma/dead body was about to roll past your room.
Maybe they were about to stick the toddler next door for blood and knew it was going to be noisy.
Every person in the ER makes eye contact with the nurse walking by the room, they are all waiting for something. It's not a big deal to us. You are having delusions of grandeur.
I'm a pediatric floor nurse and we have to chart q2h. If pt has IV running continuously we have to chart q1 (just initial box that says we checked their IV)... but an actual note at least q2 for all pts.
Specializes in Emergency, Critical Care (CEN, CCRN).
In our EC, you only have to do the big narrative note on initial assessment and if the patient experiences a major status change. Other than that, it's chart by exception. Our policy calls for rounds q30m on Priority 2 and q1h on Priority 3 patients. We have all electronic charting in the EC, though, so you can throw in your notes very quickly - some nurses have even created templates for theirs and just change the complaints and interventions to whatever their patient is actually experiencing. It rarely takes us more than five or seven minutes to chart an assignment's worth of notes.
Our typical rounding note looks like this: "Pt re-assessed at this time, VSS, c/o nausea and abdominal pain 7/10 for which received 1 mg Dilaudid & 4 mg Zofran SIVP per order; pt states pain now 2/10 and nausea resolved. Pt updated to status and plan of care, agrees. Comfort measures offered, side rails up x2, call light in reach. Will continue to monitor." --or whatever you actually did for your patient.
canoehead, BSN, RN
6,909 Posts
Maybe they were trying to protect you from the chaotic ER.
Maybe a bloody trauma/dead body was about to roll past your room.
Maybe they were about to stick the toddler next door for blood and knew it was going to be noisy.
Every person in the ER makes eye contact with the nurse walking by the room, they are all waiting for something. It's not a big deal to us. You are having delusions of grandeur.