Documentation woes!

[TangoLima]

I'm wondering if all hospitals require the same silly documentation requirements as ours does. Our facility is up for JCAHO accreditation, and they are getting more persnickety, and it is driving me crazy.

We have a tri-fold flowsheet. VS are charted on a graph in one area of the flowsheet. Yet, when we write our nurses notes, we are expected to re-write the VS next to our notes although this is on the same flowsheet, just in a different area.

Same thing with our pain assessments. We have a designated area to document time, pain rating, quality of pain, adjuvent therapy, time of reassessment, new pain rating,etc. But, then we are expected to also document this information in the nurses notes both for the initial pain assessment as well as the reassessment.

I just find this to be incredibly rediculous and a waste of our precious time. Does anyone else experience this? There just has to be a better way!

[RedhairedNurse, BSN, RN]

Gotta luv that double charting. Not! I too think it's ridiculous. Sorry to hear you have to go through that.

[mama_d, BSN, RN]

My fave at our facility is that we have to chart the labs on the flowsheet although they are readily available on the computer and on printouts which are automatically generated as soon as the lab finishes entering them...all b/c one physician group decided they didn't want to have to get the chart out and look for them and made a stink. We have to double chart the pain stuff as well. And let's not even get started on the skin/wound documentation!

[NotReady4PrimeTime, RN]

For a minute there I thought maybe TangoLima and mama d worked with me! We're expected to chart the identical information in about four different places. However, a legal advisor to a group of nurses I once worked with told us that charting the same information in multiple places leaves one open for credibility challenges if the chart ever goes to court. Let's say I document on the MAR that I gave a PRN dose of fentanyl at 0030, but when I'm documenting the same thing in my narrative nurses' note I write that I gave it at 0035, and I write in on my flowsheet that I gave it at 0035, but the PYXIS record says I pulled it at 0025. Which time is correct and how will I know ten years from now when I go into court? If it's only documented in the one, most appropriate place, in this example the MAR, there's no confusion. Some people in my unit even document all their routine meds on the flowsheet as well, which is a waste of time. And why should I write in my nurse's notes that I drew a blood gas, when the results are clearly recorded on my flowsheet?