i was given advise from a nurse who told me if you discharge a pt quickly, you don't need to document it. this brought up a red flag, and i had came across the nso website with oodles of information about documentation. i would like to pin this to my unit's bathroom door and show this to the nurse i spoke to because this is important info.
8 common charting mistakes to avoid
recording information in your patient's chart is an important part of your job as a nurse. there are many ways that charting mistakes can be made. by making yourself more aware of these eight common pitfalls, you can not only avoid making these mistakes but you can also avoid being involved in a lawsuit.
1. failing to record pertinent health or drug information
2. failing to record nursing actions
3. failing to record that medications have been given
4. recording on the wrong chart
5. failing to document a discontinued medication
6. failing to record drug reactions or changes in the patient's condition
7. transcribing orders improperly or transcribing improper orders
Like you, I was looking for a good book about documentation, I found "Documentation in Action" by Lippincott Williams & Wilkins ed 2006, I dont know if there is a newest edition. It is great book, it has a LOT of examples, notes & charts. It provides you with examples of daily documentation (basic skill) as for what to document during different challenging conditions. It also focuses on the legal & ethical implications of documentation as we know. It has hundreds of written nurses's notes that provide a model for your own notes. Well, just to let you know, I am going to look if there is a new edition. Good luck to you...
THANKS BIG TIME!!!!!!!!!! This is exactly what I'm looking for! :paw:
I am also a new grad in a Med/Surg unit, and I am VERY glad my Preceptor is all about document!! document!!!& document!!! "care not documented is care not done". I have tried to "chart" as much as I can about my pts, we also document by exception. Like you, I was looking for a good book about documentation, I found "Documentation in Action" by Lippincott Williams & Wilkins ed 2006, I dont know if there is a newest edition. It is great book, it has a LOT of examples, notes & charts. It provides you with examples of daily documentation (basic skill) as for what to document during different challenging conditions. It also focuses on the legal & ethical implications of documentation as we know. It has hundreds of written nurses's notes that provide a model for your own notes. Well, just to let you know, I am going to look if there is a new edition. Good luck to you...
You do need to document, but it is not necessarily true that you didn't do it if its not charted. Lawyers know this is being taught in schools and are taking advantage of it. A nurse can recall on habit as well, so if your on the stand and the lawyers says "it wasn't done because you didn't chart it", but if you know that you always look at a IV before you inject something to see if its bad then you are fine.
"Will continue to monitor" should not be used at all IMO. What are you going to "continue to monitor"? Just the tele and not the patient? So you were monitoring the patient, what parts? Just IMO.
"Will continue to monitor" should not be used at all IMO. What are you going to "continue to monitor"? Just the tele and not the patient? So you were monitoring the patient, what parts? Just IMO.
When I document, I write the time first. I noticed in the other nurses notes would write 7a-7p.
8am. Pt received in bed. AOx3, VSS. C/o sharp pain at incisional site 8/10. Dressing CD/I. Morphine 4mg IV given. stated relief 5 min later, 4/10.
Full assessment is checked off on the flow sheet. So I try not to double document. But I do take note on the abnorms such as pain, bruising, low U/O. After reading the articles from nso.com, now I understand to include the physician's name and time if I had to inform him/her.
I was told, state how you received the patient (if there are changes later, it can easily be compared). If there were vital sign issues, they would be noted otherwise VSS is vital signs stable. The pt was in pain, I noted the location, intervention and evaluation. Should it have a conclusion? ex: "continue observation"
Then I would try to chart around noonish if there was anything new, if the pt left the floor, if I did teaching or any deviations from the norm.
Specializes in Med-Surg/Peds/O.R./Legal/cardiology.
Amy0123,
Perhaps it would be a good idea to make a copy of this nos article to present to the DON. Do not mention your nurse manager's name, just ask for clarification as to how to handle this issue (ie: "I'm not quite clear on this and am getting conflicting opinions"...)
I did question her, she said "it would save time", it was "insignificant and assessments need to be complete" for quite a few surgical admissions that had followed after the discharge. I got the impression that there is no time for charting so whatever is least priority in charting, let it go.
I suppose I'm just not understanding what she was getting at by "discharge quickly". Weird. But of course you have to chart on a discharge. Discharge paperwork (meds and instructions, follow-up appointments/when to notify MD, home care, etc.) is a biggie. Let risk management, JCAHO or some other inspectors find out this isn't being done...
That saying from nusring school " if it wasn't charted it wasn't done" I firmly believe in. I have noticed that alot of the nurses on the shift before me will not chart that they checked and verified placement of a Ngt or Peg, residual or if they had to give a bolus feeding, continiuos feeding or free water.
Not me, I chart and chart and get laughed at cause of my charting, but hey it is my License's and Butt!! not theirs.
As a chart auditor, I love great documented. It helps identify care and helps coders recover (bill) money for the hospital. It also plays into how much staff will be hired, in a round about way. A good coder will find documentation that supports an insulin injection was given that may not have been charged for, recovering potential revenue loss for a hospital/clinic.
I have been with the OIG when they review medical records. They will not cut anyone slack for poor documentation. I would rather face an attorney any day, then an auditor from the Office of Inspector General (OIG).
amy0123, BSN, RN
190 Posts
THANKS BIG TIME!!!!!!!!!! This is exactly what I'm looking for! :paw: