Charting Issues

You chart YOUR findings, not someone else's. Some stuff can be copied forward- like if someone has a R BKA or is blind in his left eye, that will always be true, but other things can change.

the version of Cerner (e-charting) we use- there is no copy option, you'd have to select the same fields/options as the previous nurse. I had a patient about a month and a half ago that had a Right full arm fiberglass cast from her knuckles to mid-upper arm. previous nurses had all charted that R upper extremity pulses were 2+. There was no way to check radial or brachial pulses on that patient's arm. i charted "unable to assess" in that field and instead charted on cap refill. God forbid anything happened to that patient and we were called to court and the lawyer asks "the patient was in a full arm cast- how did you check pulses in that arm" I'm not going to put myself in the line of fire. In the end most of my stuff will match with the previous nurses assessments unless someone had a cardiac rhythm change or LOC change. CYA and chart what you see, not what someone else 'told" you.

Yeah it's paper charting and everyone is just checking off what the previous checkers checked but when I go down the halls and see that someone doesn't have a certain safety feature I chart otherwise. I let the DoN know that I wanted to talk to her about this today but there was not enough time. It's concerning to me. I partially feel like I shouldn't bother with it because in essence it's not my problem because if something happens on my watch they'll see that the resident didn't have the appropriate items to stay safe. At the same time I care about what's going on.

Suggest to the DON that staff need further education on charting correctly. See, you reframe the issue. The new and higher expectations will be explicit after such education. Offer to help set up an inservice or 'review' during staff meetings. Volunteer to do chart auditing (this is a requirement of facility certification).

Otherwise, how other people chart is sorta 'mind your own business'. You've handed the issue off to the DON, been willing to help him/her with changes. You've done your 'bit'. That's where you draw the line, and keep doing your job. If nothing changes, it's more than staff needing educated, it's a management issue. That's when I start looking for work elsewhere OR let go of the issue and focus on myself.

Suggest to the DON that staff need further education on charting correctly. See, you reframe the issue. The new and higher expectations will be explicit after such education. Offer to help set up an inservice or 'review' during staff meetings. Volunteer to do chart auditing (this is a requirement of facility certification).

Otherwise, how other people chart is sorta 'mind your own business'. You've handed the issue off to the DON, been willing to help him/her with changes. You've done your 'bit'. That's where you draw the line, and keep doing your job. If nothing changes, it's more than staff needing educated, it's a management issue. That's when I start looking for work elsewhere OR let go of the issue and focus on myself.

This is the perfect answer. Thank you so much, I've just felt guilty holding off on the issue for so long it's been getting to me.

We had a QC person that I could go to instead of bringing everything to DON. Chart what you see. I hate the copy and paste charting and I never do it.

I agree with the above posts, that you need to chart what you do and what you see regardless of what other people chart. And if there is a QA person that should be the one who is checking the charting, not you. The DON needs to be aware of the inaccurate charting and an education session needs to be officially organized and attended by the staff. You might be called out by your co-workers but it is a matter of professionalism and licensure, fraud etc. It is a serious offense to not chart accurately, no matter where you work. I did find that the LTC facilities I worked were rather lax in their documentation and it is easier for others to just chart what was there already. But one has to question, did they even assess the pt? Sometimes there is a language barrier or they do not know how to document correctly, they need to be taught if this is the case. It should not be hard to rectify, but it does need to be addressed. Kudos to you for being an active advocate!!

I worked in a hospital years ago in which a patinet had come in for surgery, had complications, went to ICU then downgraded to a medical unit. In the hospital 5 weeks and her skin assessments were always fine till finally someone actually LOOKED and she had a Stage 4 pressure ulcer. Hospital and everyone who touched that patient was sued. Not a good idea to chart what you do not assess. I would go to DON and ask about policy.