Documenting and not DOING anything for pt's.

oramar · Mar 9, 2008

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.

:yeahthat:

Excellent post. Neither the nurses who spend too much time with their paper work or the ones like me that blow some of it off just to have more time with the patients are the villians here. The system sucks.

CaLLaCoDe, BSN, RN · Mar 9, 2008

the squeeky wheel gets my documenting vote everytime!

meaning: those situations that would lead to possible misjudgement by the nurse of what a sensible nurse would do; those situations when family complains about my nursing care, that it was lousy; yet i know i did my best; those times when the patient crashes as in a code or a rapid response transfer....then i chart...otherwise the other times i chart it is just fluff and i'd rather be caring for patients than charting to infinity.

this gets my vote of being the most hotly controversial topic of the year! way to go op!

caliotter3 · Mar 9, 2008

The house supervisor told me one time, "If you aren't going to do anything about something you've observed, then don't chart your observation." Judging by how that place was operating, that edict was widely followed. When State was due to come in, several were scurried off to back rooms to "redocument" certain situations. Blatant false documentation, demanded by the DON and the supervisors. No wonder that when I left, there were two lawsuits going on.

Personally, I only wish there were enough time to do what we need to do and chart it appropriately. Since I'm not Speedy Gonzalez when it comes to doing things, it would make it a lot easier on me. I can only speed myself up so much before I become disorganized and unsafe. I don't think anyone should be required to exceed their physical, mental capabilities in order to leave the shift on time. And there is a difference between being slow and deliberate, and being too slow for the job. JMO

MaryAnn_RN · Mar 9, 2008

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!).

I was involved in a really nasty incident last year; pt septic, massive amounts of noradrenaline, respiratory failure, renal failure, coagulopathy...the lot. Pt being nursed on a high dependency unit. No beds available on the ICU. Decision made to commence haemofiltration on high dependency despite this pt needing one to one nursing care. Reason? No beds available and consultant did not want to move pt out to another unit within our critical care network.

To cut a long story short pt died, there was an investigation, I felt like cr*p having tried so hard to get the right care and treatment for this pt in an appropriate unit. You can bet your bottom dollar I wrote everything down as it was happening, but it didn't help the pt any. What it did do was provide evidence to the investigating manager and to my union that I had acted appropriately.

Another thing I won't do anymore is accept a 'verbal' instruction, if they don't chart it then I won't do it. Simple as that. You want me to give that pt ativan? Fine, then get off your *ss and come to the unit and prescribe it.

I do try to work in a spirit of teamwork, all there for the pt etc etc. However when it hits the fan, you bet the doctors won't back you up.

Virgo_RN, BSN, RN · Mar 9, 2008

I find myself in the opposite situation. I find that I am so busy doing things for the patients, that I have little time left for charting. It is a good shift when I can strike an appropriate balance between direct patient care and documentation.

I find my time is typically nickel and dimed for the first hour or so of my shift, doing things such as refilling water pitchers, bringing warm blankets, getting boxes of tissues, helping patients to the bathroom, etc., while I should be looking up my labs and planning out my care for the evening.

Or when I go into a patient's room to give one little pill, and they need more water, a blanket, to go to the bathroom, or want to clean up for bed.

What drives me bonkers is when I finally have a moment to sit and catch up on my documentation, and a patient/family member sees me sitting and makes an assumption that I am not busy, or doing anything important, so they ask me for a pillow, some ice water, or come rushing out of a room to tell me that their family member (who I do not know at all, because they are not my patient) has to go to the bathroom NOW and somebody better come QUICK or there will be a BIG MESS to clean up.

I feel that the documentation at my facility is a reasonable amount, though the way the computer program is set up is a bit inconvenient (they are working on improving that). For me, this problem underscores the importance of either A) Hiring more CNAs so that my time is not nickel and dimed constantly or B) Hiring more nurses and giving us each fewer patients.

I don't mind getting blankets and ice water, but when you have a really busy shift and many tasks to complete, these are not high priority actions. On the other hand, I have a hard time telling a patient "Sorry, I'm too busy to get you a warm blanket/help you to the bathroom/soak your dentures.", so I usually just do these things while getting further and further behind.

Just last night, a CNA loudly complained that a nurse down the hall had come "all the way down the hall" to find her and ask her to get a patient off the commode. She said the nurse could have just done it in the amount of time it took her to come down the hall. I had to bite my tongue, because I could not think of a tactful way to explain to her that the nurse was probably swamped and rapidly sinking, and probably hadn't even had a dinner break nor had any time to pee, and would probably be staying late to chart, and that she did not come down the hall on a whim or a power trip, but desperately needed the help, which is what the CNA is there for.

Sorry, got off on a tangent sort of. I think this balancing act between charting and bedside care is a struggle for most of us. I don't think it's right that we have to choose between patient care and documentation, because both are fundamental.

Blackcat99 · Mar 9, 2008

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.

It's true.:oIf you didn't chart it then it wasn't done in the eyes of the state inspectors. We just had a state inspection and my boss was fired because things were not charted but they had been done. Of course, overtime is not allowed at my facility so we would have all been fired if we actually stayed over all the time to chart everything. :madface:

RN1982 · Mar 9, 2008

Charting is important but the needs of the patient do come first.

CHARTING PROTECTS YOU in the event that you may be pulled into court because the patient or family sues you. If something happened during your shift and you failed to document it, you bet they are going to ask if you called the doctor or what did you do to treat you patients low BP, etc.

For me, I only chart if something significant happens i.e. abnormal labs, abnormal vital signs, respiratory distress, new admits, the list goes on.

The whole point of charting is to show that you noticed something with the patient was wrong and what you did for it.

I'm not the type of nurse that is going to chart that the patient had a pleasant night.

I agree that the needs of the patient come first. But I do believe that if it wasn't charted, it didn't happen. I'm not going to take another nurse's word for it and put my license on the line. :twocents:

RN1982 · Mar 9, 2008

Another thing I won't do anymore is accept a 'verbal' instruction, if they don't chart it then I won't do it. Simple as that. You want me to give that pt ativan? Fine, then get off your *ss and come to the unit and prescribe it.
I do try to work in a spirit of teamwork, all there for the pt etc etc. However when it hits the fan, you bet the doctors won't back you up

I agree. I will not take any verbal orders from the house docs. Its too much of a liability if you ask me because say you asked for some morphine for your patient and they give you the order the next day they can come in and say "I never ordered that".

If I feel something is wrong and my gut instinct tells me that crap is gonna hit the fan soon, I let the doctors know that I want them up there and now so we can get the problem under control.

DutchgirlRN, ASN, RN · Mar 9, 2008

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.

why does one just have to understand that god knows that they lied?

wrong is wrong if they are charting things they are not actually doing. all i have to understand is that i am doing my job and my charting honestly and above board. what i do understand is that they will one day have to answer for their dishonesty/laziness whatever you wish to call it.

leslie :-D · Mar 9, 2008

it drives me nuts to read nn's that state a boatload of interventions they did, when i know it was never done.

pt repo'd q2h (yeah, tell that to the festering stage iv on their coccyx)

iv sites nonred, nondraining (as we're treating acute phlebitis)

pt denies pain (as i listen to the groans in the next room, nevermind vs through the roof)

appt remains poor, denies nausea, no vomiting (note my emesis-stained scrub top)

no s/s of bleeding (oh, you didn't notice the blood stained sheets? or what about the packing in his nares?)

large, formed bm (really? funny, i just disimpacted 50 lbs worth)

and on and on.

it's not only the pts that are f.o.s.

but if it was charted, it was done.

try to prove otherwise.

leslie

DutchgirlRN, ASN, RN · Mar 9, 2008

it's not only the pts that are f.o.s.
but if it was charted, it was done.
try to prove otherwise.
leslie

:yeahthat:

Rabid Response · Mar 9, 2008

Last week my boyfriend was really sick with the flu. At one point he was pretty grouchy and whiney and called out to me from his bed, "You're a nurse! I'm sick! Why don't you nurse me???" I told him, "I AM nursing you! I've been charting on you all day!" Needless to say, he did not get the joke, but I had a good chuckle to myself.