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?
I suspect computer charting has only made things worse. In the time it takes to log on, click all the various findings, find all the data you need to document, I could be doing a lot more. I could fill out a flowsheet in half the time it takes the computer.
It is very wrong to not do something and chart that you did. I can also imagine a work culture where some nurses are overburdend and feel that they can only survive by "cutting corners".
it is very wrong to not do something and chart that you did. i can also imagine a work culture where some nurses are overburdend and feel that they can only survive by "cutting corners".
while charting something you haven't done is wrong under any circumstances...i think the issue at hand here is not "cutting corners" but rather sitting on one's butt and charting that they did everything they were supposed to have done. :uhoh21:
It is very wrong to not do something and chart that you did. I can also imagine a work culture where some nurses are overburdend and feel that they can only survive by "cutting corners".
I once found a small but perfectly formed pressure ulcer on a patients elbow. He was on 2 hourly turns and there was no mention of this on the turn chart. Mentioned in report at the end of the shift that there was a pressure sore. Came back that night and the turn chart had been completely re-written; total work of fiction.
Perhaps we should have an annual fiction prize for the most inventive charting.
I would like to say, GOD BLESS EVERY ONE OF YOU WHO WORKS IN A HOSPITAL SETTING! I have been a RN for 12 years and I lasted about 2 weeks as a Discharge Planner before the manic pace of the job ran me off (in addition to the mean spirited SW's that comprised the department)! Reading these posts makes me keep my antacids close by! Documentation is so crucial to the nursing profession and so easily overlooked! We all know what is like to follow behind someone who documents something that clearly was not done. First, it is falsification and secondly, it can be traced back to the nurse. I have been involved in a case where the OMG investigated a death in Hospice and it was my documentation that saved me! I worked on a case in LNC where a patient who was on a pureed diet was being fed peanut butter sandwiches by the nurse so the patient would go away and she could get her work done. The woman choked and collapsed on the floor. The nurse had documented the woman was stumbling and just fell in the hallway. An autopsy was performed and the sandwich was found to be blocking her airway passage. So, it is a reminder to us all (including me) to remember those are legal documents and charges ranging from negligence to manslaughter can arise.
For myself, I would just as soon have video recorders in the room, and a speaker where I can add any more relevant data. The technology exists, and it would take up less storage space than the stupid paper charts, but imagine all the crap it would uncover. No more covering up bad care, or lack of resources.
i once found a small but perfectly formed pressure ulcer on a patients elbow. he was on 2 hourly turns and there was no mention of this on the turn chart. mentioned in report at the end of the shift that there was a pressure sore. came back that night and the turn chart had been completely re-written; total work of fiction.
whoa.......
perhaps we should have an annual fiction prize for the most inventive charting.
it would be interesting and also to see how many contestants there are. what shall we give for a prize?
What makes computer charting hard for me is that there's not a system that's exactly the way I would like for it to be. Since I don't even know exactly what I want and have only charted on one and a half systems, that makes it difficult to get a system that works like I want.
One and a half systems being, one in flux with only vital signs charted on it, and one full system where you could in theory put it all in there. The system I work on now also includes the paper ICU flowsheet trifold thing which I LOVE, because if I can't leave the room to walk ten feet and chart then I can actually write everything on it, and it has served me well. Drip titration sheets? Pfft. I scribbled it there on the flowsheet. Notes? See that stuff that fills up the entire thing? Yep. Anyhow.
My other problem is the old schoolish training of how to do my narrative notes that apparently isn't going away no matter what the computer tells me to do. It comes in REAL handy when the crap hits the fan and my documentation actually paints you a picture, so you know what was done and it ain't fluff notes. Narrative charting doesn't have to be long either, but if I take the time to write it down then I took the time to do something about it beforehand.
One of the posters mentioned that a boss had said something like " if you're not going to do anything about the observation then don't chart the observation." I would like to alter that to say "if you're not going to do something about what you observe then go find another job." Really.
Sometimes our equipment doesn't work right or gives a skewed picture. Then I chart that it took some doing to get accurate readings and how I know they're correct... like, what's the clinical picture. Description of good perfusion despite the bp, or what's the MAP and how do I know it's adequate for this patient. Or, the readings are correct, they are in the toilet, the patient clinically is in bad shape and was made a DNR, and the doc is aware with no new orders. That's doing something, and it's a shame that you gotta chart it just to cover your butt, but hey your butt and your family will thank you when it saves your license.
So with the computer charting, what little I do know is that there need to be less redundant stuff. Little "checklist" features are nice but they lead to charting that could be just checking it whether or not you did it. I don't check it if I can't back it up. Sorry I didn't have time to turn soandso during the code, I am not checking that I did, you'll just have to live with it. I don't agree with the whole idea of nursing diagnosis but I'll agree to assign them to my note via the very easy system we have. However I'm only making ONE narrative note for one time slot, not one per nursing diagnosis, for the love of peter in a fish basket. The very suggestion of making four notes for two a.m. is enough to make me consider having the people who think this up committed involuntarily, to MY locked unit, with me holding the leather restraints.
Specializes in OR, ICU, Tele, Psych, LTC, Palliative.
I think it comes down to having too many chefs and not enough cooks. Too many bosses to answer to; nursing supervisor, ministry, JHACO, lawyers, doctors, paperwork and the list goes on. Our only consideration should be the patient. Period. Our fear of not charting, documenting everything we do to cover our patooties, has gotten way out of hand. I was told back in the old days, mind you, that
excessive charting is nothing but fodder for a lawyer to pick apart in a courtroom. We chart for the legal system. We must keep in mind that everything we chart will be looked at by a court.
Nothing like a bit of fear to get the adrenaline moving, eh? In the quest to make sure the paperwork is done, we've forgotten the main reason we're there. The patient. Is it a wonder why teenagers would rather go into the computer field than put up with this nonsense? Sigh.
For myself, I would just as soon have video recorders in the room, and a speaker where I can add any more relevant data. The technology exists, and it would take up less storage space than the stupid paper charts, but imagine all the crap it would uncover. No more covering up bad care, or lack of resources.
That's a good idea. I would prefer they mount a camera with speaker on top of my head so they can actually SEE how much running around and chaos there is everyday. Then at the end of the day I could chart,
"Performed the best care I could under present circumstances as a nurse, CNA, and unit secretary. Shift was short 2 RNs, had no unit secretary and no CNAs."
Then again.....I don't want to give management any ideas.
RNperdiem, RN
4,592 Posts
I suspect computer charting has only made things worse. In the time it takes to log on, click all the various findings, find all the data you need to document, I could be doing a lot more. I could fill out a flowsheet in half the time it takes the computer.
It is very wrong to not do something and chart that you did. I can also imagine a work culture where some nurses are overburdend and feel that they can only survive by "cutting corners".