Charting versus care

[schilm15]

I should first start off by saying I am a new nurse. I received my LPN in Aug 2014 but started working as a nurse in April 2015. I have close to 5 months of experience as a nurse working part time (24 hrs per week, 3 PM - 11 PM) at a rehab facility. The patients I typically encounter are weakness r/t a fall or surgeries such as a knee/hip/spine. We are treated as a subacute care hospital so we get the lovely extensive computer charting called ITW to where we chart many different prompts on behavior, even if the patient doesn't have any behavioral problems. Needless to say, it can take me two to three hours to chart correctly if I have the typical 8-10 patients. We chart a lot about patient teaching which seems to take up a lot of charting and time. I am the type of person who likes to do things right and not take short cuts just to get out on time. I do not like laziness. However, I'm having a hard time juggling dressing changes, achs accuchecks, two med passes, and pain meds (mainly pain pills and sleeping/anti-anxiety meds) all while assessing my patient and making sure their needs and questions are met/answered. Our policy on patients who have fallen is for them to be on alarms for the first 3 days they are at our facility then to reevaluate and d/c if indicated. If patients have alarms then of course they can't be on the toilet without staff (cna/nurse) being with them in the bathroom. So a lot of times I will be trying to help the aid toilet if she's stick in a bathroom with such patients or helping her transfer a patient if the other aid on the hall is busy. I firmly believe teamwork means everything. My problem is I'm having a hard time juggling time spent charting between time spent at the bedside. Others have told me to not be detailed in charting but I don't like the idea of cutting corners because it's a very selfish thing. I am the one who monitors the response to medications and therapy and communicates it to the MD/therapists and don't see it fair to the patient to not chart accurately. I am a fairly fast typer (60 wpm) so that isn't the problem. Most times I get about 30 minutes of charting time during my shift and the rest of the charting is after I've given report to the next shift nurse. I get out 2-3 hours after my shift and this not only makes me appear slow and incompetent but makes me (and I'm sure other nurses and the charge nurses) frustrated about the overtime. I feel like I have to choose between good care but sloppy, short charting vs quick care, concerns not getting addressed, responses getting overlooked and patients feeling uncared for but good charting, basic needs met, charge nurse/other nurses happy, and I get out on time. Does anyone have ANY advice or feel the same way. Maybe I just am destined to be an ICU nurse but I just want my patient to be cared for and feel that they are cared for while also having good, accurate charting and leave work when I'm supposed to. I have the feeling a talk will eventually happen if I keep getting out late. A (eat-your-young-kind-of) nurse told me matter of factly that they will eventually make me clock out to chart if I keep staying over late to chart but I didn't even think this was legal in the state of Indiana. Needing advice/opinions desperately!

Signed,

Newly stressed nurse

[hawaiicarl, BSN, RN]

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

[Karou]

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.

[RNperdiem, RN]

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.

[schilm15]

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.