Documenting and not DOING anything for pt's.

RN1982 · Mar 10, 2008

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. :twocents:

Silverblitzen · Mar 11, 2008

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. :specs:

RN1982 · Mar 11, 2008

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.