Documenting and not DOING anything for pt's.

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Specializes in med surg/psych/home health/hospice.

Hi people, am I the only nurse that disagrees with " If you didn't chart it, it didn't happen?" Because from what I have witnessed on floors, is that if you are busy DOING things for your pt's, the truth is you DON'T always have time to chart it. I have seen nurses sitting at stations all evening charting they are doing things, however, their patients have not even seen their nurse! CUZ she is to busy charting she is doing things, that she obviously is not attending to. ISN"T that falsification? Lying, dishonest? What lawyer made that up? And what foolish nurses agreed that this is a correct way to document?

When nurses are TOO SCARED to forget documentation, resulting in ignoring their patients, things need to change! I have seen urinals full, ( nurse is at her computer charting) pt's lying in waste waiting to be cleaned ( nurse still at computer charting?) Pt's bell not being answered ( nurse busy charting). When will this change so nurses can be free to TAKE CARE and pay attention to the patients??? My nn is a joke as i always chart at the end of a shift, and I DO EVERYTHING I can , while that pt is in my care, to make their stay as comfprtable as it can be. Someone needs to realize this and change it. I will start! With computers the problem is even worse because it takes SO long to log in, you hate to log off and on. resulting in staying at the computer to finish.

Several nights there were actually 3 nurses at the desk ALL evening charting!! We had 5 on the Cardiac ( mind you) floor. Their pt's did not even know who their nurse was!!! They said t me, "gee I thought you were my nurse". When I was actually their LUCKY roommates nurse. So I did things for their pt's , because I felt so bad for them that they had no nurse to tend to them. But you bet your life they were DOCUMENTING all this work they were doing. What a sin, are we not better than that?

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Specializes in OB, M/S, HH, Medical Imaging RN.
hi people, am i the only nurse that disagrees with " if you didn't chart it, it didn't happen?"

i have seen nurses sitting at stations all evening charting they are doing things, however, their patients have not even seen their nurse!

that's called falsifying documentation which is a blantant lie and is illegal. i believe nurses like this are in the minority. it doesn't only pertain to nurses. i have worked with cnt's who charted all their vitals and never took a single bp. whoever falsifies their documentation is behaving criminally.

what is meant by "if you didn't chart it, it didn't happen"? is a completely different matter.

say that your patient was going downhill fast and you called the doctor and he didn't give your call any merit and didn't give you any orders. the patient ends up coding and dies. you didn't chart that you had called the doctor. the family sues. you get called into court. you testify that you knew the patient was taking a downhill turn and the doctor was notified but no orders were given. the doctor says he did give orders. you did not chart anything regarding the incident so who are they going to believe? if you didn't chart that you had notified the doctor you cannot prove that you did by swearing to tell the truth. it has to be in black and white. that is what the saying is referring to.

now i have a question for you? why is your id "worstnurse1"?

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I think it's better to take care of the patients and forget the charting. Things do need to change!!! Thanks to jcaho we get more and more paper work ad less and less time for our patients. However what those nurses you are talking about are doing is called falsification of records, flat out lying. Sad!!!

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Specializes in OB, M/S, HH, Medical Imaging RN.
i think it's better to take care of the patients and forget the charting.

unfortunately they deserve equal merit...legally speaking ;)

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Yeah you're right but if it comes down to between the 2 I'd rather take care of the patient. We mainly chart in case we go to court. In 19 1/2 years I've never been to court and was only involved with 1 lawsuit and it never went to court-mainly due to good charting. And yes I'm knocking on wood. God I hope I just didn't jinx myself. What I am really trying to say is I would rather do more for my patients than I remember to chart, than to chart more than I do

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Specializes in med surg/psych/home health/hospice.
that's called falsifying documentation which is a blantant lie and is illegal. i believe nurses like this are in the minority. it doesn't only pertain to nurses. i have worked with cnt's who charted all their vitals and never took a single bp. whoever falsifies their documentation is behaving criminally.

what is meant by "if you didn't chart it, it didn't happen"? is a completely different matter.

say that your patient was going downhill fast and you called the doctor and he didn't give your call any merit and didn't give you any orders. the patient ends up coding and dies. you didn't chart that you had called the doctor. the family sues. you get called into court. you testify that you knew the patient was taking a downhill turn and the doctor was notified but no orders were given. the doctor says he did give orders. you did not chart anything regarding the incident so who are they going to believe? if you didn't chart that you had notified the doctor you cannot prove that you did by swearing to tell the truth. it has to be in black and white. that is what the saying is referring to.

now i have a question for you? why is your id "worstnurse1"?

im the worstnurse to ask for positive feedback on becoming a nurse. ill tell you go into another field.

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hi people, am i the only nurse that disagrees with " if you didn't chart it, it didn't happen?"

although this isn't the point of your thread, i do agree with your first statement. as for the remainder of your post, i agree with that too, and it's nauseating that folks are ok with performing their job that way. i'm guessing if they were the pt., they'd like to see their nurse actually come in and do what they say they are doing in their charting--or maybe they'd prefer to be left to lay in bed and expect a miracle to occur to inprove their acute condition.

what is meant by "if you didn't chart it, it didn't happen"? is a completely different matter.

say that your patient was going downhill fast and you called the doctor and he didn't give your call any merit and didn't give you any orders. the patient ends up coding and dies. you didn't chart that you had called the doctor. the family sues. you get called into court. you testify that you knew the patient was taking a downhill turn and the doctor was notified but no orders were given. the doctor says he did give orders. you did not chart anything regarding the incident so who are they going to believe? if you didn't chart that you had notified the doctor you cannot prove that you did by swearing to tell the truth. it has to be in black and white. that is what the saying is referring to.

ok, so before i say anything else...i do not advocate not charting (sorry for the double negative); it is absolutely essential to your license. however, the above saying is something that has been perpetuated by malpractice lawyers. the fact is that it is absolutely impossible to chart everything you do; to do so would require someone following you to record your every move. and if you happen to appear in court and you failed to chart something, a good lawyer might be able to prove that you did something without it being charted, but one probably shouldn't base their practice to depend on their lawyer to get them out of a jam.

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Specializes in OB, M/S, HH, Medical Imaging RN.
yeah you're right but if it comes down to between the 2 i'd rather take care of the patient.

how does that saying go? penny wise, pound foolish...:twocents:

i would rather do more for my patients than i remember to chart, than to chart more than i do

:yeahthat:

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Legally if you didn't chart it then it wasn't done. Which is unfortunate because if you are a really good nurse working in a crummy place, you probably do not chart all that you do because otherwise they would fire you for getting off late all the time. Unfortunately, the people who chart that they did something and didn't do it are less likely to have someone prove that they lied. In that case, if you are a Christian, you just have to understand that God knows that they lied.

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Specializes in ER.

If I need to choose between charting or care I go with care every time. Not just because the patient is there for care, not paperwork, but because if the patient feels you attended to their needs and were responsive they are less likely to name you in a legal action, even with a bad outcome.

If I knew absolutely that I would have a bad outcome on a shift, and that the family would take it to court, I would still focus on the care as opposed to charting for that reason, and because I might be able to prevent an even worse result.

If you are having a truely rotten shift and can't get a relationship with the patient, or the doc is not answering calls, whatever, you usually know ahead of time to chart carefully, and to chart every detail. I recently charted every call bell ring on a patient, and it proved that not only was she demanding, but that it was impossible to complete the tasks she requested between callbell rings. I swear it would have been funny (ding!) had she not been such a (ding!) pain, and threatening legal action (ding!).

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Specializes in Community Health, Med-Surg, Home Health.

Joint Commission and the fear factor is what makes nurses spend more time documenting than doing patient care. It is hard to find a balance when you are trying to do both each and every day, because you never know which patient may be a potential law suit. It is unhealthy to resign ourselves to the knowledge that we HAVE to stay more hours to document in order to give patient care, but may not be getting compensated for it. The med-surg nurses at my hospital have been intimidated into not putting in for comp or overtime by being told that "if you have to stay after your shift to document, then, you are using poor time management skills and it WILL reflect in your evaluation (and it has actually happened to them)". Also, I think it is a danger to remain on the floor for too long after your shift is over because if something else happens on the floor and you are present, you may be expected to respond. I stopped having lunch in my clinic because of this. The staff lounge is in another building altogether. I hated going there because on the way, I run into many patients or administrators that ask or demand my attention and I cannot really say 'no', so, I would take my food out and go to a 'quiet' area. When people know I am there, they would come in and say "Oh, since you are here, can you please do this blood pressure check (or injection, nebulizer, etc...)". If I say no (and I have, sometimes), then, I am wrong. If I do it, I don't get those 15 minutes back.

Some nurses take to documenting charting everything at the end of the tour, which, I try to avoid doing, because I forget pertainent information. Other times, there is really no choice. Basically, people are doing all that they can do to survive in an arena that is asking for impossible things to be done and the rules change daily.

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Unnecessary charting is the problem. I have always charted the important things. There are so many things we have to chart in multiple places. Take for instance accuchecks. It is not unusual for an evening med/surg nurse to have 7 or 8 to do at 5pm then again at 9. The vast majority of the places I have worked required that number to be written at least 2 times and many have had 3 places to document it. Once place on some sort of board for the staff and docs to look, another to be sent to the lab and another in the computer for pharmacy. Once place I worked tried to do it one place in the computer but that resulted in everyone having to stop and look it up so we had to go back to the old way. And that is just one thing, there are a million things like that. I think the charting I hate the most is the kind that makes life easy for some state or joint commission inspector so they can sit on their ass in office and look up everything they need but makes life more difficult for me.

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