Documentation

jag nurse, RN · Sep 13, 2019

On 9/10/2019 at 7:22 AM, LovingLife123 said:
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!!

Oh my. I totally getcha...100%! I'd also like the docs to work the floors. Hey, maybe there should be a J.C., Insurance, Provider month, where they work the floors, and we'll sit behind a desk, make the rules, and ding them on not charting appropriately! Lol

HarleyvQuinn, MSN, RN, NP · Sep 13, 2019

10 hours ago, DahliaDaisy said:
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.

Yep. Always a blast when my patients are banging on the nursing station windows demanding attention while I'm trying to complete the mountains of documentation about them. Take a worksheet for group out there since they refused to go to group, though, and they scatter into the wind. I have to document that too. ? Even if we move them from one unit to another because Supervisor wants to open up more beds to get more patients in. Gotta throw in a note: "Patient moved from appropriate unit to less acute unit due to acutely aggressive psychotic patient in the ER needing a bed per supervisor." I mean, come on.

rvzohfeld, BSN, MSN, RN · Sep 13, 2019

On 9/10/2019 at 8:22 AM, LovingLife123 said:
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!!

I hear you and I am with you. I have been there and done that. It is easy for someone to say, document as you go. My story is that on my last day of work at a facility (after giving my resignation) I was placed on what is known as quite hard mission (won't go onto details). from 9:30 am to 4:30 pm. I had a total of 16 patients under my care. Let me mention, not all at the same time. They were being discharged one by one, except one that was an surgical ICU overflow patient. So I had to managed all my patients going home plus attending to the needs of this patient who had quite some issues while a bed was assigned. I had no other choice than to make notes and chart after... I stayed until 7 pm, charting. That was the best I could do in order to literally keep everyone happy and safe. I had to prioritize and put patient care before charting a thing. Why do this happens? My theory is that many of the facilities are simply short staffed, management wants to do more for/with less. As long as we are not in a leadership position or we lack "seniority" we really don't have much of a voice. There are many rules and regulations that look beautifully written on paper, but they are just not put in practice. If a nurse complains or says something about it (I have seen it), we are basically told to grow thick skin. Sometimes we are just flagged as not dimmed fitted for the profession and end up leaving for the next "best" place and so on.

I have seen many nurses leave/quit over safety concerns, patient rations (you name it)... and it is all swept under the rug as: "he/she is just leaving to care for family, moving, or will take some time off.. any excuse, but the real reason. That is what means leaving a work place in good standing. Never said a thing, every thing was good, not a problem, and the life of a nurse goes on....

LovingLife123 · Sep 13, 2019

They were both patients that were circling the drain by shift change. Both ended up dying despite our efforts.

One was young, one was old. It was two days of long conversations with families. That’s draining in and of itself. But then you have to go back and chart all the new devices, why they went to a gcs of 3. And that’s all fine. They need that info.

But then there’s all that extra. And it’s like what did I forget. Oh, that dysphasia screen on the intubated pt. Did I put their learning assessment in? Did I tailor the education specifically to them? I want to say no, their pupil was blown, I was emergently intubating, getting a stat head ct, and discussing the grim prognosis with the family.

I mean, does the rest really matter? That’s my point. JHACO and their ridiculous requirements contribute to burnout.

We are getting our visit soon. And the big discussion I guess is ligature risks as DaveyDo has pointed out. I just shake my head. To me, they focus on the absolute wrong things.