Charting systems question (fighting with management)

  1. Hi there,
    I am looking to see if there are acute teaching medical wards (tertiary care)out there that are not using point of care charting. This is, does anyone NOT keep or record data at the bedside.

    We are starting to implement computerized charting at our hospital (I am in Canada and we are WAY behind the times). Phase one starts next week but will not involve nurse charting yet- just lab result retrieval and pt reg. at this point. Anywho, the powers that be for some unknown reason have removed all door charts and we now only have one main pt chart for everything, kept at the main desk of the ward.

    So, if you need to record or access info like VS, an accucheck record, your flow sheet you have to go to the main desk, look for a chart that is usually not there and then delay your charting. We always (past 14 years) have had our vital signs record, nurse's care flow sheet- like for chest sounds, dietary intake, etc., accucheck records on a clipboard in a holder onthe pt's door. This data was then filed int he pt's chart either at the end of the day or when the sheet was full depending on the type of document. I have never heard of issues with lost documents while we used this approach. All wards in this hospital not under this particular director are still using the door chart approach.

    It had a cover on it stating that the info inside was confidential and I cannot say that privacy issues came up very often at all. I have only in 14 years had maybe 2-3 instances where people accessed this info without asking and in all cases it was family members or the pt themselves so I really do not think privacy issues are in play here.

    This has been a huge burden on the nursing staff and has made the quality of their documentation suffer. We share the main chart with med students, attendings, OT, PT, SW, HC, etc etc. I instruct students on this ward and it drives me nuts when they bring me a BP or accucheck result and I have to hunt high and low to find out the pt's trend/baseline before giving more direction.

    Perhaps there is no one left with paper charts out there...but if you can think back, and your area is applicable- i.e not LTC or ER, etc., please let me know how you conducted your charting. Even with the electronic charting I know all evidence supports point of care recording as this saves time and increases accuracy. I am not sure how anyone can support this centralized approach from a nursing perspective. I would like to hear arguments supporting the centralized approach so I can better prepare for battle against the management.

    Brenda RN (currently working as a clinical nursing instructor soon to be returning to my old job as Clinical Resource Nurse on the above discussed unit)
  2. Visit bren3299 profile page

    About bren3299

    Joined: Mar '06; Posts: 29; Likes: 10
    Nursing Instructor
    Specialty: 13 year(s) of experience in Internal Medicine


  3. by   miko014
    We are on the way to being paperless, but right now we still do assessments and a few other things on paper. They are kept in a smaller chart that sits on a nurse server outside the pt's doorway. It sounds like, as far as that goes, we do the same thing you used to do. But all of our med admin, labs, VS/I&O, etc, are on the computer.

    I have been on units where they keep everything in the nurses' station, and I agree, that is a HUGE hassle! It really defeats the purpose of "real tiem charting" if you have to search high and low to find the chart. Also, who has time for that??? Oh, I'm sorry Pt A, I couldn't get you you pain meds on time because I was looking for pt B's chart...I dont' think that's gonna fly. And also, when I was on that unit, there was a lot of "double charting" going on - ie, you cant find the chart, so you make a note somewhere else, then when you do find the chart, you have to write it all down again. Talk about a waste of resources!!

    There was one unit I was on a long time ago where they had 2 separate charts, but both were kept in the station. That was a strange system...but it worked better than just keeping everything in the same place.

    I don't know if this is the answer you're looking for, but hopefully it helps!
  4. by   bren3299
    Yes I am looking for this type of info. I bet most feel the way you do. I am hoping the vast majority of wards have a bedside charting system for the components that make sense like VS, etc. I plan to bring this to the attention of the director when I present our case. I have developed surveys for the staff (health care aides, nurses, ward clerks, doctors) to assess everyone's feelings about this change but these are with the manager right now and I hope they are not going to tell me I cannot circulate them as I will be forced to go to above their heads on this issue. I believe it is a case of an employer directly impeding on the nurses' ability to practice safely. I think things are quite different here in Canada but I would appreciate any ideas on how to fight a bad policy (not that this is hospital policy as it is only being done on 2 wards).

  5. by   mydesygn
    I'll start with a question - Are you working on a floor or is this an ICU?

    My experience has been that shortly after HIPAA (Health Information Privacy Act) came into effect, we removed all documentation from the patient bedside and we were paper charting at the time. Oddly enough, it was not a difficult transition for us for 2 reasons -- 1) nursing documented on a separate form (flowsheet) than the other disciplines (ie dietary, physicians, physical therapy who documented on a progress note) This progress note along with any patient orders were kept in the main chart at the nursing station 2) nursing documentation was kept in a small separate binder also kept at the front nursing station. With the exception of the docs reviewing nursing notes in the am and the occasional nursing student, the only staff using the nursing binder was the assigned nurse for that patient so I rarely had any issue finding my nursing flowsheets. Sometimes in the am, I would even pull my flowsheet for that day (which I kept on a clipboard that I kept with me) and leave the remaining nursing flowsheets in the binder (the docs typically wanted the I/O for the previous shift and would ask the nurse directly for any current information); after morning rounds, I generally replaced them. Our staff kept a paper taped to the door inside the patient room on which the nursing asst (and the family) kept track of the patient intake and output. Usually the nursing asst would record this information on the nursing flowsheet over the course of the shift.

    When I was in the ICU, we did keep the entire patient chart at the bedside which is reasonable considering the number of disciplines and documentation -- however visitors in the ICU are strictly controlled and patients (and the patients chart)are always within the view of the staff.

    Truthfully, easy access to confidential patient information should be a priority and personally I'm surprised the facility is just now implementing policies to change that. Fighting removing charts from the bedside is probably going to get you nowhere, particularly given that it is common practice in the United States. What I would focus on is ways modify your documentation practices to facilitate an easier transition and workflow. NO SYSTEM WILL BE AS FAST PERIOD. But the real priority is the patient's confidentiality. The method I described above works well on the units I have worked on.

    I currently work at a facility that has computerized nursing documentation as well as many other disciplines ( Phy Therapy, Case Management..) also document on the computer. Having come from the world of paper documentation, I missed the speed but honestly I would never trade that for what I and my patients have rec'd in safety, accuracy, completeness and accessibility of information. I have been involved in a lawsuit and it was my documentation that saved me, trust me, the little inconvenience was far worth the threat to my license and my job. Now Canada may not be as litigation fraught as the US but I can't imagine that not being a real issue for your staff

    Focus on creating a well designed system and not on resisting the change.
  6. by   bren3299
    Thanks for your reply, I figured the only real argument for this method would be that of privacy. Unfortunately, the staff were never told if this was, in deed, the reason for this. I should let you know more about the situation. This is an acute internal medicine ward with 34 patients, many with renal failure and we do peritoneal dialysis on this unit as well as having a variety of other pt conditions.

    I am not fighting this change because it will make my life easier as I am a Clinical Resource Nurse (charge nurse), so my job is centered at the desk and having all the pt info at the main desk is actually better for me. It is not, however, better for our over-worked, under experienced staff who we have right now. This is a ward in crisis with very junior staff and daily safety concerns due to an inequality between acuity and experience and chronic short-staffing. They need every spare second they can muster.

    Thing is, there has never been a case where a patient, family or other individual has brought an issue of an invasion of their privacy to light when using this system. No one has ever had a complaint nor has there been a negative consequence from a privacy standpoint. This is where I feel evidence must support the practice. Is there a greater risk that someone could access this info that shouldn't be..(which, by the way does not contain diagnosis, prognosis, address info, etc.)? Yes. Has this actually happened in all the years it has been done? No. The charts are not right inside the room but rather by the door so accessing these charts is obvious to any staff member in the hallway at the time. On the other hand, there have there been real delays in treatment with real physical consequences and a noted and marked decline in nursing charting quality since the change. I feel this is a matter of pt safety which outweighs privacy in my opinion.

    Also, as I mentioned, this is not a permanent change in policy as we will have computer documentation beginning in less than a year. My issue is that they choose now, when this ward is in crisis, to place yet another hardship on these nurses. Other wards are not doing this. Easier wards. If this were true hospital policy, I agree that I might have to find a way to live with it, but clearly this is not hospital policy if only 2 wards out of about 32 are doing it.

    So my argument will be to leave things as they were and had been for the past umpteen years until the computerized system is implemented...this fall. I feel this will be viewed as an act of good faith by the nurses on behalf of the management and show support for this staff who have been having a mass exodus of late (they have lost over 12 nurses in the last year totaling over 200 years worth of seniority to lighter wards and all were replaced with nurses with less than 1 year experience...well not all were replaced- hence the chronic short staffing.)

    The very issue you raise of poor documentation is the thing I am trying to address with opposing this action. These nurses are not charting VS done at 0800 until 1500... this is not timely. They are trying their best, but sometimes they do not begin any charting on their pts until after 1400 on the day shift...this cannot be good from a legal standpoint. I believe in integrated progress notes and have no issue with this. Perhaps if management will not budge then the idea of at least having the nurse's clipboards separately at the desk as you describe may work as a compromise. I feel this still removes the accuracy and timeliness of point of care charting that is supported by the evidence but I could live with it if it helped the nurses do their charting more promptly and completely.

    I am leaving a teaching position and summers off to return to this place and try and help out where I can. I will hold off my actions until I have results of the surveys I drafted as I need to be sure the majority feel the way that those nurses who approached me with the problem do. I support decisions that make sense but I am having real trouble with this one.

    Thanks again for your thoughts,
  7. by   mydesygn
    I understand the nursing staff's frustration and being overburdened and staff departures. Guess what , I hate to sound cruel -- but every change made on a nursing unit has been fought using those same arguments. I heard that when they wanted us to code to barcoded medication -- I heard it when the took charts from the bedside -- I heard it when they took Potassium vials out of floor stock and not one person thought how much safer this is for the patient. The goal is to PREVENT the problem and demonstrate that as a hospital that you value and protect your patient's privacy.
    The plan may be to go to computer documentation at a later time but the issues you are having will not go away with the computer, as a matter of fact, they will amplify. Most nurses do not computer document AT THE BEDSIDE -- you are to busy, typically you write the info on paper and then document at a later time when you are able to. You can have a computer at every bedside but most of your documentation is in bursts away from the patient room. I'm not sure waiting until computer documentation is in place is really a good idea, you will have a lot of issues transitioning to nursing documentation, you really need to be part of that process -- this is the time.
    This is the opportunity to begin that transition and by helping to design the process so you will have something that enables patient privacy as well as complete, accurate documentation.

    I think privacy does however need to be facility wide and not limited to a single unit. This is actually the real issue. Administration should be working with all areas to implement protections in a manner that is equal and known by all staff.
    Last edit by mydesygn on Mar 31, '07
  8. by   bren3299
    You are sounding a little like me now. I am forever convincing the staff about the benefits of change and trying to calm the naysayers when we have a change in procedure or a new system implemented. I have been a "super-user" (their term- not mine) for every new pump, medication system, etc. as it has come down the pipe. I am one of those people who thrive on change. I flip my jobs every 4-5 yrs for this very reason. I am a trainer for the hospital with the new computers as well and have spent many of my classes convincing people of the benefits of this change while they grumble away. I take issue with those people who are afraid of change and refuse to see the benefits because they are caught up in all the negativity. I annoy those types with my gung-ho attitude. I also analyze each change for aspects that could be improved upon before I jump on board, however.

    I just don't believe that this charting change makes sense. I do believe in protecting a pts privacy but only using measures that make sense. We still have the fluid balance sheets on the door and this has the pt's name and medical numbers on it (it is addressographed) so the other sheets like a vital signs record, I don't feel, has any more info that would compromise the pt's privacy. I mean what could someone do with a blood pressure reading that would invade another person's privacy, really? Our privacy act (PHIA) is alive and well in this hospital and we all sign a pledge, etc. I just think we have to be careful not to go overboard and be protecting pt's privacy in ways that are not balanced with the risk. We have a cover on the bedside data that states the info is confidential-I think this is sufficient for the degree of risk.

    I do think you have me pegged as far as the privacy thing sometimes rubbing me wrong. One of the big reasons I had issues with the privacy act was that nurses were then denying family any info over the phone. So when the 80 year-old wife of a pt on the ward would call to see what type of night her husband had, people would just say they cannot release any info. I had a problem with this. The pt wanted his wife to know, his wishes were not being followed and we now made his wife worry for no good reason. Some nurses would release info, others some type of info and the more staunch ones would say absolutely nothing beyond what pt inquiry would say like "stable". Pt satisfaction surveys indicated that poor communication with the family regarding the plan, etc. was one of the primary problems they had with their hospital stay. So, to address this I (forever the change agent) developed a release of info form for the pt's to sign when they were admitted to our unit. On it the pt could give their permission to release info over the phone to family, or only to give info in the pt's presence, no info released, etc. It also allowed them to name a spokesperson for the information thereby saving the nurses' time if the family had many members calling in succession and we would direct other members to the pt's chosen spokesperson. It worked quite well as it respected the pt's wishes, left families less stressed and pts feeling like there was better communication. Often, I just take a phone to the pt's bedside and let them speak to the family member directly. Our pts must pay to rent a phone in their room so many do not have this (I think it is horrible that we do not provide in-room phones for our pts) Of course, others cannot communicate and we must speak to families for them.

    If you have point-of-care charting devices with a computer system I don't get why people would write things on a paper first and transfer it later. This seems inefficient. If they are too busy then it should be apparent that recording the data twice takes more time. It sounds like a vestige from the old way of doing things and that people have not fully embraced the evidence-based method of real-time charting. Research supports charting data as you gather it rather than waiting and doing it in "bursts". We have to try and make this work with the new computer system and I am glad you have pointed out this as an issue as I will be trying to get staff to take full advantage of the time saving properties of real-time charting. It takes a big change in approach for some that are used to writing things down. Charting right at the bedside rather than outside the room should also reduce the risk of other people seeing the info you are entering on the screen- thereby protecting pt privacy.

    I am really going to advocate for the bedside thing as it is making more and more sense as I ramble on about it right now.

    Thanks for getting my juices flowing about this. This is the discussion I need to help me in my quest. (I have also surveyed my fellow nursing instructors to find out what other hospitals are doing. They have told me that all the acute wards have beside charts. So it does look like we are an island in the storm- a big strength for my argument).
  9. by   bren3299
    I originally discussed this matter at the following link-

    Since posting this information, I have finally found out why the changes to our charting system were made. As I said, we are WAY behind the times and our hospital was still using Nurse's Notes rather than integrated progress notes. The majority of staff was very much in favour of having integrated notes even though it meant having to fight for the main pt chart to enter them at times. One older nurse (allergic to change) made a comment about this change within ear shot of the director that went something like, "Well if I can't get the chart then I just won't be making any notes." Obviously a tad extreme and silly a position.

    In response to this lone comment the director decided she would force all nurses to HAVE to go to the chart by putting all chart components in there- VS record, glucose monitoring record, etc. Things that should be kept by the bedside- and still are in all other teaching hospitals in our region. None of the changes had anything to do with privacy at all. They were to punish a nurse for a comment and now we have all sorts of complications (see previous post for details)

    What are your opinions on this? Is this abuse of power? I have decided that because it is not hospital policy, a nurse could decide to not conform if they so chose. We are part of a professional body (and Union) and we are to govern our own practice. I have surveys drafted to review the nurses' positions, mucho literature supporting point-of-care charting, etc. If I present this to her and she doesn't budge do you think we could just revolt...and put the door charts back? Again, this is not hospital policy but the actions of one knee-jerk dictator who wouldn't be able to fire us anyway. We live in Canada so this is public health care.

    Let me know what you would do....I tend to be a bit like a dog with a bone so I think I know what I will be doing but find feedback here very valuable.

    Brenda, all fired up in Canada
    Last edit by NRSKarenRN on Apr 14, '07 : Reason: merged threads
  10. by   CHATSDALE
    i am sure that canada has different patient confidentuality [hippa here] but is keeping records at bedside proper...are these notes accessable to visitors and/or non-nursing employees??
  11. by   Mulan
    I really can't comment since I'm not in Canada, but are your nurses going to get overtime pay to stay and do the charting that is now going to take much longer to do?
  12. by   bren3299
    Regarding privacy, there is no info about diagnosis, etc kept near the room (the bedside charts are just binders with a cover stating the info is confidential and the only stuff in there are vital signs and glucose results and things like the pt has edema, progress notes, no test results, etc.) This binder is not inside the room but out in the hall by the pts room- anyone attempting to access it would be seen by staff. I stated this in a previous post "I do believe in protecting a pts' privacy but only using measures that make sense. We still have the fluid balance sheets on the door and this has the pt's name and medical numbers on it (it is addressographed) so the other sheets like a vital signs record, I don't feel, has any more info that would compromise the pt's privacy. I mean what could someone do with a blood pressure reading that would invade another person's privacy, really? Our privacy act (PHIA) is alive and well in this hospital and we all sign a pledge, etc. I just think we have to be careful not to go overboard and be protecting pt's privacy in ways that are not balanced with the risk. We have a cover on the bedside data that states the info is confidential-I think this is sufficient for the degree of risk.

    Again, all other areas do this so in the health authority's opinion, it is acceptable practice from a PHIA (our version of HIPPA) perspective.

  13. by   bren3299
    We are guilty of not claiming the overtime we have on this unit. With so many junior staff there are many times when people are there up to an hour after the end of their shift- saw 3 of them still there 45 minutes after day shift ended today. No one claimed overtime. I will be encouraging nurses to claim for it whe I start my regular charge position May 9th. I am guilty too. I was there 45 minutes over due to a staff meeting (regarding the new computer system) and didn't claim it but think I will ask the manager to approve it on Monday as I am back that day. You are right that consistently forking over more money would get their attention faster than most things.
    I am just amazed that a person in this position would use their authority to try and enforce an unapproved change in charting policy. I have to wonder if this is some sort of breach of some ethic/policy somewhere.
  14. by   CritterLover
    Quote from bren3299
    i am just amazed that a person in this position would use their authority to try and enforce an unapproved change in charting policy. i have to wonder if this is some sort of breach of some ethic/policy somewhere.

    i don't know about a breach of ethics or policy, but it shows really, really, really por management skills.

    it is the equivalent of saying "how dare you complain! well, i'll show you. i'll make it really tough. hah!"

    it sounded like the nurses were bringing up legitamate cons to the new system, and it is up to the manager to come up with a workable solution. this doesn't sound like a workable solution.