Charting

At my hospital we are to chart by exception. In ICU we have in-depth flowsheets so we don't need long nsg notes, but most people usually do end up with at least 1/2 page of NN anyway. Do we need it? Probably not, but it's better to double chart than to under chart IMO.

We use Metavision which has an in-depth assessment for us to go through and pick out descriptive items for (i.e. breathing 1) labored 2) nonlabored, etc.). We can put a comment on anything in the assessment, and also put notes for doc notification, critical lab values, procedures, events, etc. It's pretty thorough and I think I've had to hand-write a note maybe once ever.

Chart according your hospital's protocols, because that's what will save your butt if it ever goes to court

I hate charting. In my ICU have computer charting, and we chart an assessment at least every 4 hours, vitals and I&O's every hour, turns and restraints every two hours. Of course we chart every point of care test, every med given, and every titration. Certain high risk drips require two nurses to chart a change of rate, which is really a pita. I hate having a patient on an insulin drip because we must take and chart blood sugars every hour and then find another nurse to double check our insulin rate changes before they can be charted in the MAR. Every shift we must also chart patients' plan of care and education on special spreadsheets. To top it off, within the first two hours of each shift we must access our mainframe and enter our GRASP scores for each patient. I'm sure I've forgotten to mention some aspect of our charting, just as I'm certain that I forget to chart stuff all the time at work. There is so much of it, and it seems that all of it must be accessed through a separate spreadsheet. I am used to it now, but it still takes a very long time to chart everything, and I know that there are times when time spent charting takes away from patient care. We are pushed to chart in real time, and the computer will register WHEN you chart something as well as the time you are charting about so charting everything at the end of your shift looks really really bad.

What really makes me feel bad is that patients and family members see me charting (we must chart on carts in the room or just outside) and assume that I am ignoring them or their loved one. The patient is right in front of me, but I am face to face with the computer and can give them only a fraction of my attention. Ugh.

I'm a new grad working in an ICU. We have electronic charting. I actually like it, but maybe that's because I never had the paper version. My entire assessment, titrating of drips, lab draws, etc is charted by clicking in a box or a drop down menu. My preceptor wants me to start writing narrative notes throughout the shift but main to capture anything out of the ordinary such as disruptive behavior or something that is way out in left field. I've had a few docs tell me that they usually looks for a nursing note before scrolling through the rest of the chart because the narrative paints a better picture of what truly is going on with the patient. :mnnnrsngrk:

We have paper flowsheets that are 8 pages long, then another sheet for our plan of care, another sheet for skin assessment, another sheet for restraints, another sheet for heparin gtt titration, another sheet for insulin gtt titration, a sheet for patient education. I'm probably leaving something out, but that's what I can think of off the top of my head. So, a lot of stuff that I do throughout the shift is captured in one way or another on these documentation sheets. I have read/heard that it is not good to "double chart" i.e. write something on the flowsheet, then re-write it in your note. This is because any discrepancy could be used against you in court, i.e. on the MAR, you indicate you gave a med at 2015, and in your note, you write 2010.

At any rate, I am probably an "over-charter". I write a fairly lengthy note at the beginning of shift. It usually write "Received report from XXXXX RN, assumed care" then describe the patient's LOC i.e. "A/Ox3, with periods of confusion" or "Responds to vigorous verbal stimuli, follows commands, unable to assess orientation d/t intubation but responds appropriately to Y/N questions." I make sure to always address respiratory status i.e. "Lungs clear but dim in bases, resps even and unlabored, O2 per 2LNC" or "Vented per ETT at 40% FiO2, IMV 8/500/+5 PEEP." Then I describe any "abnormal" findings on assessment especially if they are related to admitting diagnosis i.e., "+3 edema to RUE, pedal pulses non-palpable, confirmed by doppler, ecchymosis to L orbit, decreased bowel sounds". I make sure to document any lines/tubes/drains i.e., "NGT to LIS with thin green drainage, or Gtube with Pulmocare at 40 mL/hr, or Foley draining cloudy amber urine with sediment, JP drain to midline incision with bright red thin drainage, AVF to RUE with +bruit/+thrill". I describe any gtts or IVF and where they are infusing i.e. "NS @ 150 mL/hr to RUA PICC dated 4/15/10, or Propofol at 40 mcg/kg/min to LIJ TLC dated 4/15/10." I also make sure to describe any wounds/incisions i.e., "midline abdominal incision, OTA, approximated with staples, edges dry and pink, no erythema or exudate observed" or "multiple area of skin sloughing to RLE, cold to touch, toes black, pedal pulse absent on doppler". Then I document any safety measures i.e, "SCDs to BLE, or soft wrist restraints to BUE, see restraint flowsheet, or bed alarm on, or Prevalon boot to LLE". I also document any education or instructions given to the patient i.e. "Reminded patient of NPO status after MN for stress test in AM, verbalized understanding" or "Instructed pt to call for assistance and rise slowly from bed, verbalized understanding, call bell in reach".

Then, I chart anything significant (not routine turning, mouth care, or bath) I do during the shift such as:

*Calling critical labs or changes in condition to the MD, what time I paged them, when they returned my call, if new orders are given, etc.

*Changing dressings to wounds, central lines.

*When I give PRN meds and why

*When I initiate or titrate gtts and why

*Trach care

*Road trips

*Any procedures, such as placing an NGT, foley, or INT

*Changing O2 modes and why

Then I write a brief note at end of shift i.e., "Pt asleep in bed, resps even and unlabored, cont on vent on same settings, pt remains NPO, VSS, NAD."

Sorry for the long post. Hope it helps answer your question.

My pet peeve is the bad charting nurses do. If you are computerized, you should not need lengthy notes. Every section, respiratory, GI, etc, has a tab for a little note. Charting is by exception! If you get hauled into court, all your long notes will get dragged through the mud. If you are sitting there for hours charting that a pt looks good, watching tv, then you are neglecting your patient and doing to much charting!

A care plan is to be done on admission, then updated ONLY the next day. If something new happens on your shift, then start a new one, but some nurse start care plans for every area of the body.

If you are in the respiratory section, and you check the box for 2l nc, then you don't need to write that anywhere else. Get back to your patients and stop overcharting!

We also have a very in-depth charting system, and our q 2hr charting includes, vitals, phys. assessment, vent settings, skin care/turning etc. We have separate interventions we can chart on as needed for gtt titration, MD calls, critical labs, etc. I chart narratives whenever a procedure was done, when I recieve an admission, any significant change in status.

i have been told by nurses who went to court and nurses who worked for law firms analyzing cases.... do not double chart. it gives them more room to nitpick if anything doesn't match exactly. i still think we have to chart way too many stupid thingss way too often....

and i feel like having a positive interaction with patients and their families keeps me from even going to court in the first place... if i have made them feel important and that i care... they are less likely to take me down for being wronged.

anyone share my same ideas?

What does the law require as far as the bare minimum required?