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?
Patients do come first. But if you don't document in the patient's chart what significant events that occured with the patient and what you did for it, you are just as bad as the nurse who documents that they did something and they never actually did it.
If you think charting is not important, you'll change your mind after you are hauled into court.
Specializes in OR, ICU, Tele, Psych, LTC, Palliative.
Patients do come first. But if you don't document in the patient's chart what significant events that occured with the patient and what you did for it, you are just as bad as the nurse who documents that they did something and they never actually did it.
If you think charting is not important, you'll change your mind after you are hauled into court.
That's my opinion.
I don't recollect saying that charting wasn't important. Documenting important events is vital for continued, seamless care of the patient. However, if we documented everything we did, we'd not have any time to actually care for the patient. That's what I was getting at when I related what I'd been told in the "olden days". Even in the 80s, before managed care and HMO's, we were warned against excessive charting, and I emphasize the word excessive. Scientific writing is boiled down, factual and to the point - words like "appear" and "seem" are not part of the lexicon. These are words that a legal mind would leap on in an instant and if you were hauled into court, you'd be sitting there trying to give a good example of why Mrs. Smith "appeared" to be in pain. Sgt Friday always said, "Just the facts, Ma'am. Just the facts" So be it.
I don't recollect saying that charting wasn't important.
Did I mention you in my post? I don't recall that I did. I was just stating my opinion. It wasn't intended to refer to any specific post in this thread.
RN1982
3,362 Posts
Patients do come first. But if you don't document in the patient's chart what significant events that occured with the patient and what you did for it, you are just as bad as the nurse who documents that they did something and they never actually did it.
If you think charting is not important, you'll change your mind after you are hauled into court.
That's my opinion.