Documenting

[Morguein]

I was just curious; how many of you write a nursing note in the progress report everytime you work? I have to admit that I don't do this every shift I work, because I figure everything I have done or was done to the patient is documented on my flowsheet. Our flowsheet is very detailed; but I still see nurses around me always writing progress notes. When I have time, I do read the progress notes from my fellow nurses regarding the patient I'm taking care of; and usually they pretty much repeat everything from their flowsheets. So, I'm thinking it's just all repetative and a waste of time. The only time I write a progress note, is when something unusual happens that I can't go into detail on my flowsheet (for example, giving blood, patient coming back from the OR, a code, any procedures done, family conferences, etc...). I do write an admitting note and a transfer note on my patients. With so much going on and so much paper work to complete, I don't usually write a progress note if its only going to repeat everything I've already documented on my flowsheet. My preceptor (2 years ago) told me that it's uneccessary to write a progress note every day. I was just wondering what you all do. Thanks :)

[PMHNP10]

I was just curious; how many of you write a nursing note in the progress report everytime you work? I have to admit that I don't do this every shift I work, because I figure everything I have done or was done to the patient is documented on my flowsheet. Our flowsheet is very detailed; but I still see nurses around me always writing progress notes. When I have time, I do read the progress notes from my fellow nurses regarding the patient I'm taking care of; and usually they pretty much repeat everything from their flowsheets. So, I'm thinking it's just all repetative and a waste of time. The only time I write a progress note, is when something unusual happens that I can't go into detail on my flowsheet (for example, giving blood, patient coming back from the OR, a code, any procedures done, family conferences, etc...). I do write an admitting note and a transfer note on my patients. With so much going on and so much paper work to complete, I don't usually write a progress note if its only going to repeat everything I've already documented on my flowsheet. My preceptor (2 years ago) told me that it's uneccessary to write a progress note every day. I was just wondering what you all do. Thanks :)

If it is the policy of your hospital to chart by exception, then more than likely your summary note will be either you double charting or charting something that is not out of the ordinary (like A&O *4, SR up, resp. even and unlabored; no acute signs of distress, etc.). Even writing something about reporting off to the next shift are not necessary if you are truly charting by exception, because giving report is a normal part of the nurses' duties.

[DutchgirlRN, ASN, RN]

If it is the policy of your hospital to chart by exception, then more than likely your summary note will be either you double charting or charting something that is not out of the ordinary (like A&O *4, SR up, resp. even and unlabored; no acute signs of distress, etc.). Even writing something about reporting off to the next shift are not necessary if you are truly charting by exception, because giving report is a normal part of the nurses' duties.

Ditto, We chart by exception also and more likely than not there is nothing in my nurses notes. Our chart review nurse passes out notices every week re: what you shouldn't have charted, etc.....I've been there over 3 years and have yet to receive one. With that said, of course, if "anything" out of the ordinary happens with your patient......document, document, document, CYA !!!

[Tweety, BSN, RN]

I usually only write prn's in the progress notes, usually pain medicine, which I give a lot of.

We use computer charting and we can click and type our assessments, so I don't write a whole lot.

I guess different people have different styles. I work with a new grad who writes tons of info on the progress note, and little if any computer charting.

Some people duplicate chart, such as write "patient is alert and oriented x 3, lungs are clear". Ummm....the computer says that when you check "within normal limits" why write it down. This kind of charting isn't going to safe anyone.

[Morguein]

Thank you guys so much for your input. I really appreciate it. I was beginning to think that I was doing something wrong by not charting everyday in the progress notes even though all the info/assessments are documented in the flowsheet.