documenting

[LizzieRN0508]

Hi everyone,

I hear a lot of different things about how often you should document and what you need to document. I work 12 hr nights and I document an opening noted, along with a RN shift assessment flowsheet and then notes or flowsheets every 2 hours as I do my rounds ( I will alternate a flow sheet with a note) and then I also document pain meds, treatments, reassessments or any education in my notes. I was taught in nursing school that if you don't document it then you didn't do it. I notice that some nurses will only document an opening noted (a basic note- pt rc'd and pt is in no pain or distress), their RN shift assessment, do flowsheets and document all meds and PRNs on the medication record. On the pt's chart it looks only as if they made one note all shift. So what was the pt doing the other 11 hours??? I feel more charting should be done... even if the pt is just sleeping. What do you all think? Our hospital policy says we should document with narrative charting. Thanks in advance for the comments.

[FancypantsRN]

I always chart q2h. working nights, if nothing happens with the pt:

No changes, NAD noted. Pt lying in bed with eyes closed and unlabored resp.

Repetitive, but proves you at least poked your head in the door.

[TA123]

I only document my RN assessment, if issue/problem occur, what was done and any any nursing procedure that I performed during my shift.

[classicdame, MSN, EdD]

Nurses are there to look for changes in condition. If you do not note that you looked, then you did not look.

[GatorNurse10]

I only document my RN assessment, if issue/problem occur, what was done and any any nursing procedure that I performed during my shift.

This plus an opening note & a closing note that reviews the shift. If it was a patient who had nothing going on then the closing note is something like.. Pt resting comfortably throughout shift with no complications. Pt A&O, resting in bed (sleeping, sitting in bedside chair, whatever). Pain controlled via PRN medications. Continuing plan of care & pt safety precautions. Call light within reach.

[classicdame, MSN, EdD]

Is till think you ought to address the actual complaint. For instance, if someone is admitted with COPD you could state the O2 sats and whether or not patient is able to breathe without use of accessory muscles or can get to bathroom without assistance. Does not take much to prove you were there.

[#1ME]

Opening note, stating how the Pt is that you are resuming care of, assessment, any changes of rhythms called in from the tele tech, which will include VS and whether Pt has any chest pain, SOB, diaphoretic, etc whether MD was called, and actions taken, PRN anything being administered and why, which MD made rounds, tolerance of any transfusions. I chart a lot and detailed. Some say all you need is an assessment and a closing note, but I say that is not safe enough. Say all you charted was the assessment and closing note, and later the Pt wants to sue for something ridiculous or the Pt codes for whatever reason, and all you have is an assessment and a closing note. If nothing else is documented, well you didn't do it. I've gone as far as to keep a log for myself, of course not including pt's names or MRUNs, but a small summary of what happened. I even record why I had to stay 20 min over time (2nd admission, difficulty Pt, etc), because my facility will write you up for doing over time, even though they continually add new paper work and things for us to do. Anyway, documentation is a great defense

[tokmom, BSN, RN]

You can never chart too much. I see nurses chart once a shift. Basically stating they took over care. They think their shift assessment will cover their butts. Well..think again. In the court of law it's not enough. BTDT when I had to show up at a deposition because my name was on the chart. My paranoid charting saved my hide. The incident was 2 yrs old, but with my detailed charting, I remembered the incident.

[Guest296136]

We use all computerized charting and there are tasks that have to be entered every 2-3 hours, such as turning documentation, I&O, etc. this shows that the pt was seen and what was done at that time, if pt is sleeping we click on button that says sleeping, not done at this time. When we give a pain med there is a pain response you have to click on 30 min to an hour later this shows that you checked to see if the medication was working. Paper charting is too much work, that is why computers are suppose to be used so we have time to do all our tasks and give good pt care.

[tewdles, RN]

Worked with a nurse who didn't chart the ordered neuro checks through the night, he said he checked the patient regularly. So when the patient was found to have a significant change in LOC toward the AM change of shift the nurse had only his "word" that the patient was indeed "okay".

I was that nurse's boss and that "shortcut" cost him his job.

[ginsil22]

I have a question. I had been taught charting by exception and if something was going on with a patient I was to include all parties at the bedside by name, such as Jane D. RN at bedside, or Kira CNA assisted patient to bed. This was common practice at the Hospital too. But recently I've started working at a skilled nursing facility and was asked by another nurse to not include her name in the documentation, and that even the doctors name does not appear in the nurses notes. (I'm still going to put the doctors name... I know better here) She asked I only document unit 4-East nurse as bedside, and it's just weird seeing her name in another nurses documentation. I don't understand this request, because if I'm pulled into court years later at least its specific to who assisted me at bedside.

[classicdame, MSN, EdD]

what is the policy in your facility about documentation? Ours has an "exception only", so we chart as you mentioned but only made extra notes when exceptions occur.