Documentation

[LovingLife123]

After spending my entire past two shifts trying to save lives and not getting a lunch, would it be appropriate to just document a note saying patient is alive??? ??

Honestly, staying until 10pm documenting ridiculous crap when I’m hangry and tired is crazy. And, 2 shifts in a row!!

I would like to invite the insurance people and joint commission to have followed me the last two shifts. Then hang out with me while I try to document the crap fest that just happened. And no eating, no fluids, and no peeing because the bathroom is too far away from your critical pt.

I might still be a little cranky this morning!!

[Nurse SMS, MSN, RN]

Can you document as you go rather than waiting to the end of the shift? Document in the patient's room if you are stuck in there monitoring? Delegate more?

["nursy", RN]

Sorry, that you had to go through that. But honestly, no one should have to work like that. It's why nurses are burning out at unprecedented rates. It's why so many nurses are going to NP/PA school. It's why I left bedside nursing. I hope for your sake that those last two shifts were an anomaly, and that most of the time you get lunch and pee breaks, like a normal human being. If not, maybe it's time for a change?

[mmc51264, BSN, MSN, RN]

Time management and charting as I go helps me get everything done. Only times I stay late is if something has happened during the shift that needs extra information, if i need to send a timely email or file some sort of safety report.

We have to do hourly rounding checks and charts (I do one and the aides do the other so I am in there every 2 hours). It is easy to chart Is&Os, pain and the safety check on those checks and assessments in the morning when I do them

[LovingLife123]

I’m very adept at charting. Lol. I’ve been doing this for over 6 years.

Its the fact that my patients were trying to die on me the past two shifts and there was no time.

I’m just kind of sarcastically commenting on the fact that I just want to chart I kept the patient alive instead of what i educated their family on that day. Because my education was basically, they are going to die, what would this person want us to do intervention wise? Or a dysphasia screen on an intubated dying pt because TJC requires this.

That’s kind of the point of my post.

[Nurse SMS, MSN, RN]

It was not obvious from you post..... obviously ?

I hope you got some rest and are feeling better.

[LovingLife123]

7 minutes ago, Nurse SMS said:

It was not obvious from you post..... obviously ?

I hope you got some rest and are feeling better.

Sorry, I thought putting laughing emojis and stating I just want to document the pt is alive conveyed sarcasm.

[RNperdiem, RN]

I understand completely. Where I work, so much of our charting exists to satisfy joint commission rather than to provide a useful record of patient care.

[DesertwindRN, ADN, RN]

Hugs to you.

I really understand. I had an image of people coming out from hiding with their cameras and putting their arms around me, laughing, and saying “we were just kidding”, after a particular nightmare shift. We don’t get compensated enough. Thank the individual up “there” that we care so very much. “Time management” had nothing to do with that day.

[JBMmom, MSN, NP]

I have totally had those nights where I could never chart the number of actual titrations/drips/interventions that occurred. On those cases I did the all important skin and fall risks screens and then charted the bare minimum. I completely understand your point!! (Mine didn't always end up alive)

[DesertwindRN, ADN, RN]

“just document a note saying patient is alive”——too funny! Thanks, I needed a good laugh-out loud-moment.

[DahliaDaisy, RN]

As a new nurse, I've already come to sadly accept that most of my time will be spent writing ABOUT my patients rather than, you know, actually taking care of them. They might as well put law classes in nursing school now because that's what it's become about.