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??

[SummerGarden, BSN, MSN, 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.

who cares if patients complain about petty things??? if my butt is "on the line" because i forgot a blanket (which i do all the time for comfortable patients), then i do not need that job! in other words, i am not going to document petty stuff. threats? yes. non-compliance? yes. patient care? yes. outcomes? yes. forgot a blanket because i was coding another patient? no, that is too much documentation.

[HamsterRN, ADN, RN]

Over-documentation does not protect your butt, it's usually what gets nurses in trouble in court. When the hospital I work at switched to a documentation by exception EMR, the staff was worried this could possibly put us at risk for legal trouble. So our union hired a legal nurse consulting group to help "protect our butts" by making our case to our administrators. As it turns out, they strongly recommended we make the switch to documenting by exception.

What gets you in trouble in court is when you don't document by your facility standards, or more importantly, the standards you have established yourself in your past charting. The more fluff you chart, the harder it is to be consistent in your charting and that is far more important than what you chart and what you don't. If you chart on one patient: "patient resting in bed and alive" and you don't chart this on another patient, lawyers can argue that you didn't check to see if the other patient was alive.

Plus, it doesn't help the patient any or the other staff caring for the patient to bury the 2 important things that need to be communicated in a pile of fluffy charting.

[Up2nogood RN, RN]

It would be wisest to chart within your facility guidelines, not from advice from an Internet forum. You should ask for specifics and how to address this from your manager. Documentation is a very broad subject and your post does not distinctly distinguish what you need help with. I know it's especially important to document in home health an accurate assessment on the reason your there, and only what pertains to your case. Forget the fluff and filler, don't write a story, keep it clear/concise and that will cover your butt.

[chloecatrn]

Are you writing narrative notes about the condition of the home or the family members present? That could be part of the problem. Those aren't part of the reason you're there, and shouldn't be charted on. Make sure you're only charting on the patient, the patient's medical condition, and your physical assessment findings.

[clemmm78, RN]

I used to work with a nurse who charted like this, and I'm not exaggerating;

"I went down to see the patient who rang his call bell. Mr. X asked me if he could have something for pain. I went to the medication book to verify what his pain medications were and what his options may be. I noted that he had received a pain medication (name of med) only two hours ago but he did have XXX ordered for breakthrough pain. I went back down the hall to ask Mr. X if he wanted the breakthrough medication and he said that he did, but he also wanted some ice cream. I got him the medication and gave it to him, orally as per the order, but I had called the kitchen and they had no more ice cream. When I told Mr. X that we did not have ice cream, he asked if he could have jello instead....."

I swear, I'm not making this up. So, if you chart anything like this nurse, YES, you are charting too much. What would I have charted?

Pt requested pain medication, rating pain on X/10. Regular pain med due, breakthrough med (name) given at pt's request. Also requested ice cream but non available. Given Jello and is now resting quietly.

[dudette10, MSN, RN]

Are you writing narrative notes about the condition of the home or the family members present? That could be part of the problem. Those aren't part of the reason you're there, and shouldn't be charted on. Make sure you're only charting on the patient, the patient's medical condition, and your physical assessment findings.

Question: isn't the condition of the home and the family members who assist the patient part of the home health nurse's assessment?

[chloecatrn]

Question: isn't the condition of the home and the family members who assist the patient part of the home health nurse's assessment?

Nope, not unless it's to the point that it's neglectful. When I go into a home, I don't chart, "Four bowls in the sink. Mom wearing slippers and bathrobe prior to shower." What the family members do is the family members' business. I'm there to take care of the patient, not them. If it's neglectful, I contact the agency, the supervisor comes to the house, and the proper paperwork is filed and the authorities are notified.

[nursel56]

Question: isn't the condition of the home and the family members who assist the patient part of the home health nurse's assessment?

Hopefully that is done when the patient/client is admitted to the agency. They assess the home for possible safety issues for the patient and the nurses/caregivers. These would be things like loose area rugs on hardwood floors, unsafe amounts of clutter, etc., as well as chart a diagram of the home with the escape route in the event of an emergency. I use the word "hopefully" because of the conditions many home health nurses are actually expected to operate in and worse, some agencies will not back up a nurse who reports concerns for his or her own, or the patient/client's safety.

The only time I chart about family members is if I'm leaving the patient in their care, or assuming care from one of them. If there is a problem with a family member that we judge to be unusual (intoxicated, bordering abusive, etc) then I'd probably chart what they did/said as a quote, inform my supervisor, and proceed from there depending on each individual situation. Again, unfortunately there are agencies that don't support their nurses as they should when these things occur. Bottom line though: in my state they've severely tightened up reporting laws and I would always report those things whether I got "permission" from the agency or not.

[caliotter3]

There is information that belongs in a communication note, separate from the shift charting, if warranted, and information that does not belong on any written record that goes to the agency. The nurse is supposed to know the difference. Nuances of what is considered "too much information" may be only the opinion of the supervisor reading the notes; otherwise, it is up to the individual field nurse to determine what and how to chart. Why make more work for yourself, much less open yourself to more scrutiny?

[diane227, LPN, RN]

You will learn to trim your notes down over time but never let anyone tell you that you are documenting too much. You have to write what you feel comfortable with and remember it is you that will have to defend your documentation in a court of law. You are responsible for what you write or don't write.