Charting in hospice IPU

[gator mom]

Hello, I am a new hospice RN on a IPU, coming off a post operative floor after 10 years. We were totally electronic and charted by exception. I now am paper charting both care and MAR. I see so many different ways other experienced hospice RN's chart. Literally writing a book at times. They do their initial assessment via flowchart and then rewrite almost all of it in the progress notes. Also, documenting care CNA provides even though CNA has their own flowsheet where care is documented. I find if I do that I am always behind and spending too much time "in the chart" when I should be at the bedside. I realize I need to paint a picture of the care pt is being given, document the care provided, and show that there is reason pt must be in-pt hospice for medicare reasons. I just do not feel I must be redundant in my charting, nor write a book.

I also realize some situations may warrant more charting than others. I feel scattered in my thoughts while charting too. Guess that is from being used to computer charting and not writing out all my care and assessments on paper.

Any advice or resources that give example of proper hospice paper charting and not just someone's opinion on how to properly paper chart? The answers I have received thus far are just RN preferences. I want to work smarter not harder.

Thank you!

[sclpn]

Hello

I'm a inpatient manager and I've done homecare and inpatient nursing. I did not rewrite anything that was already some place else...I didn't rewrite the prn meds given in my narrative because they were already on the MAR etc. I didn't rewrite my assessment in the narrative either. You are correct in thinking that the nurse should "paint" a picture of the pt however, documentating in multiple places will get you in hot water when DHEC/Licensing shows up. I encourage the nurses to document along this line also but find previous hospice nurses can't let go of this heavy documentation. How to fix it is another question... I have revised our nursing forms to take away things that are in multiple areas or on another form. Not sure about your facility but here the Medical Director is sometimes the driving force behind heavy documentation and/or documentating in multiple places.

[gator mom]

Thank you for confirming what I thought. I too figured "over charting" can lead to trouble. We are supposed to be going all computer charting in near future so hopefully it will get easier. Yes, many RN's chart in progress notes every time a pain med is given with FLACC score etc. and then on pain flowsheet and MAR too. Then again in pain flowsheet and progress notes to chart outcome. This is very time consuming when giving multiple pt's frequent pain medication admin. I sure appreciate your feedback!

[PomMom65]

I work on a hospice IPU as well. Our charting is electronic with the exception of the MAR. We chart our initial assessment in a flow sheet and write a clinical narrative. If I have charted a part of my assessment in the flow sheet, I do not duplicate it in the narrative, therefore my narratives are not that long. Examples of items that are not in our flow sheet are: IV/SQ access, pump information, family at the bedside etc. I do not chart scheduled meds as they are documented in the MAR but I do chart each time I give a PRN medication with the reason and the effectiveness.

I can relate that we do spend a significant time in front of the computer.