Charting systems question (fighting with management)

CritterLover, BSN, RN · Apr 14, 2007

i am just amazed that a person in this position would use their authority to try and enforce an unapproved change in charting policy. i have to wonder if this is some sort of breach of some ethic/policy somewhere.

i don't know about a breach of ethics or policy, but it shows really, really, really por management skills.

it is the equivalent of saying "how dare you complain! well, i'll show you. i'll make it really tough. hah!"

it sounded like the nurses were bringing up legitamate cons to the new system, and it is up to the manager to come up with a workable solution. this doesn't sound like a workable solution.

Altra, BSN, RN · Apr 14, 2007

One older nurse (allergic to change) made a comment about this change within ear shot of the director that went something like, "Well if I can't get the chart then I just won't be making any notes." Obviously a tad extreme and silly a position.
In response to this lone comment the director decided she would force all nurses to HAVE to go to the chart by putting all chart components in there- VS record, glucose monitoring record, etc.

JMO, but I don't think this violates policies or ethics ... I just think it's simply an asinine response to an asinine comment.

Rather than come out "guns blazing" against your manager, I wonder what would happen if, instead, you & other charge nurses met with the manager and worked together for some other solution. Make the point that the comment she overheard was not a "revolt" but simply a lone comment made in frustration -- assure her that *everyone* collectively wants to come up with the best possible solution. Then it will be up to her to be a big girl, put away her hurt feelings, and work on the problem.

bren3299 · Apr 15, 2007

The reasonable approach is my plan. I have surveys drafted to gather actual data to show just how the change is affecting the nurses (I also have surveys for the MDs and other staff) The surveys allow for positive or neutral responses to the change as well. I will argue for whatever the majority of nurses feel will help them.

I have gathered data that states charting needs to be done contemporaneously, etc. to also help support our position. I don't intend to even mention that I know why the change was made unless this hand is forced. One of the questions on the survey does ask the respondent what they felt was the reason for the change was, as I want to illustrate that there was poor communication with the staff as to the rationale in this change of practice. I, for one, insist on knowing why I am doing something the way I am doing it.

I know that quality of documentation is a focus for her so I plan to approach it as an initiative I am starting to improve documentation on this unit. The survey is to ensure the nurses feel switching back will help so it is not just my or a few other's "opinion" but based on good data. She did this in such a knee-jerk fashion that she gathered no baseline data so now all we have is the opinion of the nurses as to whether this has made the quality of their charting suffer. Only if she rejects the data and refuses to listen will I go to "guns-a-blazing".

Barb101 · Apr 15, 2007

Hello as I am an Aussie I can only comment on what we have. We still have bedside charts mainly OBS medication & falls risk status. However we do have a allocation system. This allocates the amount of time to be given for each pt based on presenting complaints. Not a very accurate system as we can have really bad days where it all falls to pieces & the odd day where we can have lighter work loads. this system is basically a management tool& honestly does not reflect what is happening on the ward. Dont know if this helps Barb

ranchwife · Apr 15, 2007

Wow!!!!!! Now I really feel "out in the sticks", here!! :lol2: Our tiny little hospital is still ALL PAPER charting...only our lab has computers!! However, once HIPAA went into force, we had to have all patient records at the nurses station...not at the bedside where "others" could see the documentation!!

Lady Jane · Apr 15, 2007

I joined this group as I wanted assistance from my collelages re: e-doc. I am presently in the midst of "making" the prgram. The main aim - comprehensive, concise, current, clear, consistant confidential AND USER FREIENDLY!!!!! Your thoughts as what you would like to see.

Thanks

Lady Jane

:

We are on the way to being paperless, but right now we still do assessments and a few other things on paper. They are kept in a smaller chart that sits on a nurse server outside the pt's doorway. It sounds like, as far as that goes, we do the same thing you used to do. But all of our med admin, labs, VS/I&O, etc, are on the computer.
I have been on units where they keep everything in the nurses' station, and I agree, that is a HUGE hassle! It really defeats the purpose of "real tiem charting" if you have to search high and low to find the chart. Also, who has time for that??? Oh, I'm sorry Pt A, I couldn't get you you pain meds on time because I was looking for pt B's chart...I dont' think that's gonna fly. And also, when I was on that unit, there was a lot of "double charting" going on - ie, you cant find the chart, so you make a note somewhere else, then when you do find the chart, you have to write it all down again. Talk about a waste of resources!!
There was one unit I was on a long time ago where they had 2 separate charts, but both were kept in the station. That was a strange system...but it worked better than just keeping everything in the same place.
I don't know if this is the answer you're looking for, but hopefully it helps!

TrudyRN · Apr 15, 2007

OP, that DON sounds like mine - ego, ego, ego.

TrudyRN · Apr 15, 2007

I am just amazed that a person in this position would use their authority to try and enforce an unapproved change in charting policy. I have to wonder if this is some sort of breach of some ethic/policy somewhere.

Why are you amazed? She is only a human being, full of faults like anyone else. In her case, she is prideful, touchy, lacking enough confidence to face reasonable opposition (however petulantly stated), and reactionary. She, at the scenario you described involving the frustrated nurse, lacked the ability to present her proposed change in a way that would have won at least grudging agreement to at least try to adjust to the proposed change.

Does she know about change? About the older worker? Does she have no idea how congested the N Station gets or how hard it is to find charts sometimes?

You guys will have to put homing devices or GPS devices on your charts so you can find them and/or have a sign-out method so that when someone takes the chart away from the station, they sign it out by their name and destination.

Having worked mostly where charts are centrally located and nothing is at the bedside, I can tell you it is not that bad. You will all adjust because you have to pay your bills and keep your jobs and this is required. I do wish you well. Give it time. It will be fine.

nanacarol · Apr 15, 2007

You asked if the group should revolt and revert back to the "old" way. My vote is to quietly return to what worked for the group. Doing so without confrontation will allow the "manager" an opportunity to save face which comes as a result of a decrease in the volume and number of complaints. You say you are "safe" from firing, so what is the down side. It sounds as if

the manager attempted retribution for an employee's venting and made a less than well thought out decision. Help her/him out by taking the bull by the horn:)

Ohio spe aks

I originally discussed this matter at the following link-https://allnurses.com/forums/f8/charting-systems-question-fighting-management-215122.html#post2130185
Since posting this information, I have finally found out why the changes to our charting system were made. As I said, we are WAY behind the times and our hospital was still using Nurse's Notes rather than integrated progress notes. The majority of staff was very much in favour of having integrated notes even though it meant having to fight for the main pt chart to enter them at times. One older nurse (allergic to change) made a comment about this change within ear shot of the director that went something like, "Well if I can't get the chart then I just won't be making any notes." Obviously a tad extreme and silly a position.
In response to this lone comment the director decided she would force all nurses to HAVE to go to the chart by putting all chart components in there- VS record, glucose monitoring record, etc. Things that should be kept by the bedside- and still are in all other teaching hospitals in our region. None of the changes had anything to do with privacy at all. They were to punish a nurse for a comment and now we have all sorts of complications (see previous post for details)
What are your opinions on this? Is this abuse of power? I have decided that because it is not hospital policy, a nurse could decide to not conform if they so chose. We are part of a professional body (and Union) and we are to govern our own practice. I have surveys drafted to review the nurses' positions, mucho literature supporting point-of-care charting, etc. If I present this to her and she doesn't budge do you think we could just revolt...and put the door charts back? Again, this is not hospital policy but the actions of one knee-jerk dictator who wouldn't be able to fire us anyway. We live in Canada so this is public health care.
Let me know what you would do....I tend to be a bit like a dog with a bone so I think I know what I will be doing but find feedback here very valuable.
Brenda, all fired up in Canada

BrnEyedGirl, BSN, MSN, RN, APRN · Apr 16, 2007

We stopped having bedside charts about 3 yrs ago when we started computerized charting,...still have a main chart in the rack behind the nurses station but everything else is in the computer! We do have many portable computers throughout the floor as well as several at the nurses station,..there are enough that everyone on night shift can have their own computer,.not sure about days.

Rashandap · Apr 16, 2007

Where I work every patient has their own chart which is located at central nurses station. In the paper chart includes area of Dr's Orders, Progress not, Daily Laboratory Results, and Dictated Reports (H&P, Discharge Summary, Radiology Results), EKG results, Printed report of Nursing Assessments and Focus Notes, Graphic Sheet (for vital signs, I&O), Medication Administration Record for 24 hour.

Otherwise everything above and some additional information is all on computer. Our assessments, medications given, Registration, MD paging. All doctors orders are entered into computer.

There is Retrieval guide in computer that allows anyone to access an part of patients care including orders since admission, lab results, medicIations given, patients diet.

We can requests patients medications from the Pharmacy using the computer.

We can request a food tray from our dietary department using the computer.

Our patients accuchecks are automatically downloaded into the computer.

When we remove any medication from our Pyxis it is charted automatically in the computer. Our med pyxis even allows us when giving any prn medication to chart the reason we are giving meds (like if pt asks for something for pain, when going to pyxis for meds, we chart at that time location of pain, pt's rating of pain, sedation level of pt at the time of giving meds) so we don't have to worry about charting a note later. Once the medication is giving, when we go into computer to chart assessment or focus notes their will be an automatic promp asking whether prn medication was helpful, so even if you forget as soon as you go to chart you will see the prompt and can chart.

It's nice because even if someone else is using the patients chart we are still able to access patient information and record information without waiting.

We are getting ready for a new system so Dr's will have to enter their own orders so we can cut down on verbal and telephone orders.

The hospital system I work for is pretty technologically advanced. My hospital is only about 4yrs old.

twotrees2 · May 31, 2007

Hi there,
I am looking to see if there are acute teaching medical wards (tertiary care)out there that are not using point of care charting. This is, does anyone NOT keep or record data at the bedside.
We are starting to implement computerized charting at our hospital (I am in Canada and we are WAY behind the times). Phase one starts next week but will not involve nurse charting yet- just lab result retrieval and pt reg. at this point. Anywho, the powers that be for some unknown reason have removed all door charts and we now only have one main pt chart for everything, kept at the main desk of the ward.
So, if you need to record or access info like VS, an accucheck record, your flow sheet you have to go to the main desk, look for a chart that is usually not there and then delay your charting. We always (past 14 years) have had our vital signs record, nurse's care flow sheet- like for chest sounds, dietary intake, etc., accucheck records on a clipboard in a holder onthe pt's door. This data was then filed int he pt's chart either at the end of the day or when the sheet was full depending on the type of document. I have never heard of issues with lost documents while we used this approach. All wards in this hospital not under this particular director are still using the door chart approach.
It had a cover on it stating that the info inside was confidential and I cannot say that privacy issues came up very often at all. I have only in 14 years had maybe 2-3 instances where people accessed this info without asking and in all cases it was family members or the pt themselves so I really do not think privacy issues are in play here.
This has been a huge burden on the nursing staff and has made the quality of their documentation suffer. We share the main chart with med students, attendings, OT, PT, SW, HC, etc etc. I instruct students on this ward and it drives me nuts when they bring me a BP or accucheck result and I have to hunt high and low to find out the pt's trend/baseline before giving more direction.
Perhaps there is no one left with paper charts out there...but if you can think back, and your area is applicable- i.e not LTC or ER, etc., please let me know how you conducted your charting. Even with the electronic charting I know all evidence supports point of care recording as this saves time and increases accuracy. I am not sure how anyone can support this centralized approach from a nursing perspective. I would like to hear arguments supporting the centralized approach so I can better prepare for battle against the management.
TIA
Brenda RN (currently working as a clinical nursing instructor soon to be returning to my old job as Clinical Resource Nurse on the above discussed unit)

sorry this made me giggle - i am so used to NOT having anything bedside ( working LTC ) that i still have to run to the roomside holders to get the chart at the prison infirmary -