Do more forms = better pt. care

i think much of the documentation is a duplication or triplication of efforts and time and it takes from my patient care. you don't need to document the same things in 5 different places.

I think we do it for the regulators! Last year, we started putting everything in the Caretracker (computer) system. Surveyors were mad because we could get the info (meal consumtions, bowel movements) from the computer and print it out, but they wanted it in writing on paper. Therefore, we did the documentation twice. Then we talked to other facilities with Caretracker and they did not have this problem with the surveyors! We just went back to Caretracker only, and I continually look for ways to decrease paperwork for staff, but it's soooooooo hard to do!!

IMHO, most of the paperwork is to justify the jobs of those who did not like being a nurse and have moved up the ladder to the point that they are useless unless they invent things to make themselves look important and needed. :rotfl:

Decreasing the amount of paperwork adds time for patient care. Streamlined computerized charting is helping. I agree with previous posters that reams of paperwork are a delight to regulators and an albatross to nurses.

:angryfire No I do not think that more forms lead to better patient care. It seems the patients receive less care because I don't have time to actually be with them. I am too busy charting to provide the actual patient care that is needed.

If I get four admissions in an evening it means I have to jog down the hall four times and hand people their "confidentiality papers", then I have have to document it four times. Meanwhile most patients on rehab have been admitted recently from someplace else and have already recieved them. There is additional paper work to do ever since they made asking about Living wills mandatory. I don't even want to talk about extra work due to goverment tightening controls on regulated substances. These things I just mentioned are just the tip of iceberg.

in california our regulations do not dictate the forms or the methods that we use for our documentation other than the mds. we used to have the same problem with our care plans with some surveyors telling us that they were not individualized because they were generated from a computer. as long as the information is accurate it should not matter. seems to me the surveyors should have spent more time looking at the actual condition of the residents and the care they were receiving. :)

i think we do it for the regulators! last year, we started putting everything in the caretracker (computer) system. surveyors were mad because we could get the info (meal consumtions, bowel movements) from the computer and print it out, but they wanted it in writing on paper. therefore, we did the documentation twice. then we talked to other facilities with caretracker and they did not have this problem with the surveyors! we just went back to caretracker only, and i continually look for ways to decrease paperwork for staff, but it's soooooooo hard to do!!

:angryfire No I do not think that more forms lead to better patient care. It seems the patients receive less care because I don't have time to actually be with them. I am too busy charting to provide the actual patient care that is needed.

When I was a floor nurse, I used to ask, "Do you want me to DO it or just WRITE about it, cause I don't have time to do BOTH!" Of course, the reply was the same old song "if you don't chart it, you didn't do it"! :angryfire

Do more forms = better pt. care

Is this a trick question? IMO, No. The more forms we have to fill out, the less time we have to spend with the pt. We spend a third of our eight hour shift doing meds, another third doing treatments, bladder scans, straight caths, finger sticks, and the last third doing paper work, (ie) filling out forms for this and that, and electronically charting restraint notes, COS 1:1 notes, seriously ill notes, monthly notes, doing mandatory ceu's that are required for the year at our facility which can only be done on the computer, and attending inservices. Then there is the infamous emergency where someone falls, codes, has chest pains, seizures, difficulty breathing and what not. Where on earth do we even get time to spend with the pts, never mind better pt care.

Sometimes I feel the paper work to cover our butts is a major reason we often don't clock out on time.

It has to be documented somewhere and it helps for continuity of care. But often it's too much.

IMHO, most of the paperwork is to justify the jobs of those who did not like being a nurse and have moved up the ladder to the point that they are useless unless they invent things to make themselves look important and needed. :rotfl:

Lol! I've been telling my dh this for years!

Take it from someone who deals with the paperwork!!! Of Course NOT!!!!!

But because we've become such a litigious society, there has to be documentation of everything to simply cover our butts, both financially and legally. I do not, however, condone double charting. Once documented in the chart is sufficient. It is a lazy person who won't look elsewhere in the chart for the information.