Does anyone really read all this charting?

[gypsierose]

So I know I have to do it, and I know it gets crunched through a spreadsheet somewhere and some bean counter bills for it, but does anyone anywhere read all this charting I do? These hours of drop down menus that pull me away from my patients? Disclosure- new nurse.

[Julius Seizure]

As the nurse who has your patients on the next shift after you go home, yes I do look at what you charted. Especially when a patient doesn't look okay.

[MelEpiRN]

A lot of people read the chart, especially if the patient/ family has a complaint or takes a turn for the worse. If you're a part of a disease-specific program (e.g. Joint, Chest Pain Center, Stroke, etc) then there usually is someone looking at various components of every record within that program, regardless of outcome.

[BadwomanM]

I want the job of professional button clicker! I'm eminently qualified..

[Fiona59]

We long hand chart. We have an audit team that reviews.

Chart that snarky interaction because it will safe your butt when the family rants. Chart the times you paged that MIA Resident

[Ruby Vee, BSN]

We long hand chart. We have an audit team that reviews.

Chart that snarky interaction because it will safe your butt when the family rants. Chart the times you paged that MIA Resident

And chart how confused that patient is, because when they call the police to complain that "three young, beautiful nurses and one fat, ugly old cow demanded sexual favors all night long," that charting will save your butt.

[turtlesRcool]

I frequently go back through the previous nurses' assessments if I think I might be hearing/seeing something different from what I got in report. If the previous RN said lungs were clear but diminished, and I hear crackles, I'm going to be looking back through several shifts and looking at the respiratory section of the daily assessments to see if anyone else has heard them. I want to know if this is ongoing and maybe the previous nurse just didn't listen closely or if the patient has new fluid at the bases.

Since I look back in the cart for specific information, I assume others will sometimes look at my charting to compare with their own assessment. I just do the best I can with all the sections because I can't predict what might be useful to someone a few shifts off from mine.

[greenerpastures]

Lawyers.

[bgxyrnf, MSN, RN]

I don't spend much time hunting through the flowsheets but I do read the narratives that people write.

[Sour Lemon]

At my first job, there were skin assessment forms and hourly rounding forms to be signed and turned for every patient and for every shift. They were to be turned into the director daily, and I frequently observed nurses staying late and scrambling to complete them. I stacked them neatly in my locker for two years (blank) and dumped them in the shredder bin when I quit. No one ever noticed. So I'd say at least some documentation gets overlooked.

[Cafelattee]

I started nursing with long narrative charting then everyone went to the check off. I never trusted the check off style. I still write out a lot. I've seen way to many depositions.

Something to save your but is a narrative charting and keeping your pocket notes. There is no way you can remember every patients. When it comes to court. ITs the chart that speaks for you.

You also can be called in for a deposition. That's where keeping your shift report notes/work notes. It never goes to court but they call in every nurse/resp therapt and stuff that touch a patient if there is a law suit

My nurse trainers back in 90 all kept records.

The lawyers are sharks. The want to trip you up. Just something as little as forgetting to chart a b/p check can have them calling you negligent I had a patient code and in the old days we tended to not chart as we go. I finished my charting on the lady after the code. I did all my b/p but had not put them on the chart. Now days with computer timing everything. IF you went after the code to put the b/p in it would looks like you are covering your ass

There is also quality assurance department in every hospital that do random chart checks

[Orion81RN]

I have seen that good charting can save the facility a tag when the state comes in. If we are watching someone for signs of dehydration, or monitoring post fall, those are events that the state seems to love looking for the documentation that we were really on top of the follow up according to policy. I have felt the same way though, especially when we have to duplicate the same charting in three different places.

Exactly. It's the double, tripple charting that gets to me. As far as my porogress notes, I enjoy charting. (When I'm not rushed.)

I do also read other's charting when I'm needing in depth knowledge, an entire clinical picture.

[kakamegamama]

Yes, and I would hope that you, too, would read the charting of nurses who charted before you.