Charting versus care

Welcome to modern nursing. Not sure how to put that nicely. My best guess is that I spend 40-50% of my time charting/doing administrative work, and the other 50-60% doing pt care. Your situation is in no way unique. What you need to do is find a charting mentor who can show you what is the minimum required charting (yet complete), and follow it. Never doubt that this will be hard ... but take my advice and do it. Overcharting is a massive waste of time, that no one reads, document what is required for JCAHO, OSHA, Medicare, Medicaid, then move on. I think you will find that this will give you more time to actually spend taking care of your patients. Which will be more fulfilling.

Cheers

You need to develop some charting shortcuts. Are you charting by exception? That cuts down a lot of unnecessary charting when you are able to chart by exception. When you have to chart on 8-10 patients you need to be as brief and to the point as possible. Are you doing long narratives? Are you charting any more than required in an effort to be thorough? Are you charting more than your coworkers?

You are still relatively new to this facility, especially since you are part time. Charting will get easier and you will get faster. It's not about WPM/speed in the literal sense, but about being able to navigate the electronic chart quickly, and your charting be concise and accurate. Don't over chart.

Legally you cannot chart after clocking out. But your employer may find you "not a good fit" or find a way to terminate you if you keep having overtime and demonstrating poor time management skills.

Ask your coworkers what they do to chart quickly and clock out on time. Some probably have developed bad habits that allow them to speed through, but others will have helpful tips. You can also ask another nurse/charge nurse to review your charting to see if you are spending too much time on a particular area where you can cut it down.

Patient care definitely trumps charting. As bad as this sounds to say, physicians rarely read nurses charting where I work. I chart what's required and anything else they I think is important, but I don't go above and beyond because it's a waste of my time.

Good luck! Charting is probably the most tedious and loathed part of nursing for many.

As a nurse you need to prioritize charting. Not all of the charting we do is of equal priority. Who will be looking at this charting, and will this affect the patients' care?

For example, vital signs (especially) and the physical assessment are high priority. The doctors do take note of blood pressures and new onset fevers for example. The big three for me are vital signs, assessments and the MAR. I focus on those and make sure those are done first.

Things that are required by policy and are frequently audited are the next. Screw up your restraint charting, and you will hear about it.

Then there are all the rest. The checkboxes that are never looked at and do not guide patient care, but for better or worse a nurse needs to get these done. Fall assessment is done every shift. In ICU all patients are fall risk and we treat them that way, but to keep our jobs we are required to check the right boxes.

Thank you! This makes a lot of sense!! I'll pray this helps. I think I'll try a handful of things such as calling my normal charge nurse and asking her to review my charting to see if I'm charting too much and if I am asking her to refer me to a co-workers charting so I can compare and become more time efficient. I think majority of my time is patient care whether I want it to be or not. Sometimes I know I make myself behind by helping out the aid who is behind but I'm a lot of cases I can help her catch up but she can't help me so I got to be aware of this and keep an eye on it.