why double chart?

[grneyes676]

I have been reading sample narrative notes and soap notes online the last couple days, which has made me wonder.....why would you write a narrative note including all the data that should be on your flow sheet and in your shift assessment? Don't you risk making a mistake by charting the same things in 2 different spots?? Where I work, we chart our shift assessment on the back of our flow sheets.

[carolmaccas66, BSN, RN]

I do not double chart. I refuse to do it. It wastes time, there is a risk of re-charting info incorrectly, and in many cases people seem to forget to do it.

My NM agreed with me when I told her all the reasons why - she supported me on that one, amazingly. If people cannot read one chart for the info they need, then there is something wrong with the system. It is only enforced because nurses don't say no to their managers and keep doing it. We make a rod for our own backs.

[Five&Two Will Do]

I do not double chart. I refuse to do it. It wastes time, there is a risk of re-charting info incorrectly, and in many cases people seem to forget to do it.

My NM agreed with me when I told her all the reasons why - she supported me on that one, amazingly. If people cannot read one chart for the info they need, then there is something wrong with the system. It is only enforced because nurses don't say no to their managers and keep doing it. We make a rod for our own backs.

"A rod for our own backs" I like that statement. We use both the flow sheet for vitals, meds, I&O, but I do critical care notes in the computer for my assessment. They scan the flowsheet into computer everyday. It is a good system.

[LouisVRN, RN]

I agree, I will refuse to double chart. We generally chart by exception but it seems that not everything is not covered. For example nowhere in the charting are we asked whether the pt has any pain in calves or if the pt is having chest pain/dyspnea/shortness of breath. Those are always things i will chart. I will almost always document a note if the patient is not alert and oriented x3. Our only options in the flowsheet is disoriented to person/place/time. Sometimes a pt can respond correctly to questions like that but can confabulate about other things, so that to me is always worth an extra note. I want to be able to pass out on the floor somewhere after eating my report sheets and be able to have someone else look at my charting and immediately identify a change in pt condition. Also as we defer most of our reproductive assessments, i usually just ask my patients if they have any concerns/complaints. So i document this in case they later come up with something.