Documentating too much??? My agency doesnt like that

[Blackheartednurse]

OK I work for a home health agency,I'm a new RN still learning the ropes of nursing and its politics,policies and procedures.I write narrative notes and my boss tells me I document way too much,is there such a thing as documenting too much?? Sorry but it is my license on the line and I need to protect it.What do you think??

[GM2RN]

It's possible to document too much if it's redundent. If you use a software program that allows you to check off things that were done, and then you write a narrative on the same thing, that's too much. In this case, you should only narrate what's not covered somewhere else.

It could also mean you are too wordy. Some people take way too long to get to the point. You should document using as few words as necessary.

I'd ask your boss to explain what he/she means by "too much" so you have a better idea of how to provide what is required.

[iNurseUK, RN]

Can never document too much. Yo' butt on the line.

I learned that lesson early when a patient asked me for an extra blanket then the crash alarm went off. Took a while to sort the crash and I forgot about the blanket.

Yup. Written complaint.

Cover your butt. Always.

[DustaRN]

its your license...

[Flying ICU RN]

It has been my experience that an irrational fear of losing the license, is the primary cause of nurse overload and ineffectiveness.

It has also been my experience that a rational fear of losing the license keeps both you and the patients quite safe.

To qualify the above statements, you need to be able to see the "Forest for the Trees", or in other words, leave yourself free enough to provide timely and appropriate interventions. Redundancy in the record is simply that, redundant.

[SummerGarden, BSN, MSN, RN]

ok i work for a home health agency,i'm a new rn still learning the ropes of nursing and its politics,policies and procedures.i write narrative notes and my boss tells me i document way too much,is there such a thing as documenting too much?? sorry but it is my license on the line and i need to protect it.what do you think??

to answer to your question is, yes it is possible to document too much! if you document too much any lawyer can tear you apart! learn to write as succinctly as possible from the more experienced nurses in your area. have one read your documentation then ask him/her to re-write it in his/her own words to show you a better way to document the same information. gl!

[regularRN]

Go ahead and chart... chart as much as you can in a professional succinct manner. I was once called into my managers office because a pt's daughter complained that I did not solicit the pt's needs.... of course, I did but I failed to chart that the pt told me to "Get the f**k out my room"....

[nursel56]

Many nurses in my home health job document too much. Our notes are 2 page flow sheets with about 1/3 of 1 page for the narrative, in which they cram in itty bitty longhand every single thing they checked off on the flow sheet and then some. It's redundant and impossible to decipher. Therefore pertinent information is buried in there somewhere but I need a magnifying glass to find it. If they used that area to write the few things pertinent to the patient's diagnosis and anything that got worse/better it would make the note far more effective. I guess that filling out the I and O section and checking the box that says "PO" for liquid intake isn't sufficient and they add that they gave the patient a sip of water in case there was some doubt about how it all transpired.

[leslie :-D]

since there is no official statute on nsg documentation, you will find that employers have their own policy and preferences.

still, the bottom line is it's your license, and you write what you consider relevant and necessary.

i agree that your mgr needs to clarify her concern.

i've had nm's tell me to take stuff out of my notes, specifically pt complaints that i noted.

i wouldn't, and am glad i didn't...

since it was my documentation that saved my a$$, when this particular pt ended up getting legal involved anyway.

make an appt to confer w/your boss, and go over what she specifically wants and doesn't want.

only then, can you proceed and change your style accordingly...or not.

leslie

[Flying ICU RN]

Notice that the nastiest of patients have a compliance issue. In my opinion, documenting the refusal to take the nitrate, or a stick for a troponin level, is more valuable and protective of me than documenting a torrent of complaints.

[Blackheartednurse]

Go ahead and chart... chart as much as you can in a professional succinct manner. I was once called into my managers office because a pt's daughter complained that I did not solicit the pt's needs.... of course, I did but I failed to chart that the pt told me to "Get the f**k out my room"....

Wow.How freaking rude of him.On that note I work home health care and sometimes my patient have a crappy attitude.

[Nicky30, BSN, RN]

Can never document too much. Yo' butt on the line.

I learned that lesson early when a patient asked me for an extra blanket then the crash alarm went off. Took a while to sort the crash and I forgot about the blanket.

Yup. Written complaint.

Cover your butt. Always.

Oh good lord! A written complaint because you forgot a blanket?