ER Documentation

All_Smiles_RN · Nov 19, 2007

Not an ED nurse here, but I just wanted to pass along some empathy and disgust. ;-) You guys are just way too busy to stop and write a little love note every 30 minutes. Come on now management, if you want us to have time to care for our patients, quit with cumbersome requests like this.

EmmaG, RN · Nov 19, 2007

Our management has informed the ER that we are now required to document a nurse/pt. contact every 30 minutes. The effort is to increase PG satisfaction surveys.

Nice. It's only the surveys that count. Forget those ABCs. Forget actual patient care. But don't forget to pucker up while you're handing out those warm, fluffy blankets and gourmet meals.

If you go to an ER and leave there better (or no worse) than when you entered, then they've done their job.

P.S. "Any thoughts, opinions or links to related dated would be appreciated."

All ya gotta do is a search for "press ganey"... you'll get plenty of opinions LOL.

Blee O'Myacin, BSN, RN · Nov 19, 2007

Our management has informed the ER that we are now required to document a nurse/pt. contact every 30 minutes. The effort is to increase PG satisfaction surveys. I feel this is a bit too often when your trying to care and treat multiple patients. Our ER currently surveys 100% of patients. We would like to know what other ERs are doing related to pt/nurse contact. Any thoughts, opinions or links to related dated would be appreciated. Thanks

We "only" have to write a note on a patient q2h, which is reasonable with 4:1 ratio (usually) and computerized charting (back timing is OK too). But to cover my behind (our hospital is big into the pillow fluffing sunshineyness of Press Gainey), I chart all of my patient interaction so if I get a complaint that I "didn't pay mother any attention", it's all there that I "checked on patient at 0900, told patient that CT scan would be there to pick her up within the hour, reinforced that patient had to be NPO ... etc." (In fact, every time a patient asks for their ER snack - and everyone is NPO unless otherwise ordered - and I have to remind them and their posse that they can't have hospital cookies or a meal tray - I chart it. This way no one can come back to me and say that I didn't do the proper "teaching".)

But for every 1000 things that you do right, you'll hear about the 1 thing that didn't go exactly as planned.

Blee

smlm1 · Nov 19, 2007

We "only" have to write a note on a patient q2h, which is reasonable with 4:1 ratio (usually) and computerized charting (back timing is OK too). But to cover my behind (our hospital is big into the pillow fluffing sunshineyness of Press Gainey), I chart all of my patient interaction so if I get a complaint that I "didn't pay mother any attention", it's all there that I "checked on patient at 0900, told patient that CT scan would be there to pick her up within the hour, reinforced that patient had to be NPO ... etc." (In fact, every time a patient asks for their ER snack - and everyone is NPO unless otherwise ordered - and I have to remind them and their posse that they can't have hospital cookies or a meal tray - I chart it. This way no one can come back to me and say that I didn't do the proper "teaching".)
But for every 1000 things that you do right, you'll hear about the 1 thing that didn't go exactly as planned.
Blee

Question: are you an ER nurse?

frenchfroggyAPRN, MSN, LPN, RN, APRN · Nov 19, 2007

I'm lucky, I work in a small town hospital 20 beds total. We don't have to mess with the PG crap. The last hospital I worked, had them they were a pain in the "nether regions". I routinely have up to 10 patients to assess, wound care etc. plus work the ER when a patient comes in.

RunnerRN, BSN, RN · Nov 19, 2007

I work in a Level I, approx 50 beds, and our standard is a note less than q1hr,

RunnerRN, BSN, RN · Nov 19, 2007

I work in a Level I, approx 50 beds, and our standard is a note less than q1hr, but we are supposed to "strive" to chart every 30 minutes. We are also asked to check on patients q30min to update them on "delay" - use the word delay because Press Gainey specifically asks if they were "updated on your delay". I don't do that, but I do try to make a little entry every 30-45 minutes. Even something as simple as "Pt awaits CT results. Resting on cart c family at bedside. A&Ox3 in NAD." or "A&Ox3 in NAD. Updated on POC." Then do more involved notes every hour or so.

My only pet peeve is people who chart simple updates for 90 minutes or more without any assessment info. I try to explain charting standards to new grads, and they just don't get it sometimes.

time4meRN · Nov 19, 2007

We document according to their triage score. But........ I'm sure It's not long until we start documentation for PG instead of critical need. Lordy .......Lordy,,,,when will it all end ? I really think pt's got better care in the 80's when we could worry about the pt and not papaer work. All that will lead to is people documenting things they didn't do. We are human, we can only do so much. I wish we could uphold exect and admin the the same standards they seem to hold us to. The other day in our ER, we had the staffing consultants watching us. Of course me and my temper and level of tolerance (that was poor that day-- I'd had it), I walked into the nurses station and said loudly, so all these people getting paid big buck to watch us, hmmmm....when is our turn to go to their office and evaluate them------you know evaluate something we know very little about. Everyone laughed,,,,,well except for the consultants.

bill4745, RN · Nov 20, 2007

Our ER is so overwhelmed with patients that I honestly think administration wants some dissatisfaction to reduce the volume. There are no PGs, or any type of satisfaction surveys that I have seen.

We chart by acuity, with a minimum of q2 hours. Our computer gives reminders.

NicoleERRN, RN · Nov 20, 2007

I was very interested in the "proper" way to chart, basically i was told, if they are medical pts, chart Q4 H PRN or when something is done.ie meds trxs ect, Tele pts Q2 H or PRN . ICU or unstable pts. Q1 H or PRN and traumas/ codes. ect is Q 5 mins till more stable than q 30 mins or PRN. I try to chart at least every 2 hours if there is a stand still so i know ( and everyone else reviewing my chart knows)i was taking care of my pt).. this is not always foolproof but its a nice thought!!

ERRNTraveler, RN · Nov 20, 2007

In most ER's I've worked at.... Levels 4 & 5 get VS & assessment documented Q 4 hours, Level 3 Q 2 hours, Level 2 Q 1 hour, and if you've got a Level 1, it had better be a 1:1, so you would have continuous documentation....