Don't forget to document.....again.....and.....again

[Chicago, BSN, RN]

sometimes i feel the system sets us up for failure with all the constant documentation. my facility has had some recent close call lawsuits for whatever reason that all turned up frivolous. b/c of it, administration has beefed up on the documentation campaign....again. something goes down and everyone starts swarming like flies. after it dies down, things go back to the norm. but this time nothing has ceased. so the mgr announced that we all must give full documentation (as if the patient is a new admit) in our opening notes, plus every hour on the hour and closing. ok....now let me get this straight. you want me to do a full note for every patient (7+), plus complete the already lengthy preset charting that's required almost on the hour as it is. and every hour write a full note. and give meds and do patient care, b/c either the tech calls off or the nursing supervisor decides to pull ours for a unit she favors more (which is 100% of the time). before this, we already had a time consuming charting process as it is. oh and no matter what, be off the clock at 7:15. riiiiiiiiggggggghhhhhhhtttttt............

so, a few days ago, a-not-even-jesus-could-make-satisfied-patient, went so above and beyond in complaints, he requested to be moved from our unit, and was later moved again.....and again. our manager was on vacation and returned to find out how it all started. called herself reviewing the notes our nurse has made about the whole ordeal and guess what???? she documented too much. the manager went on and on about how she documented everything but began to contradict herself along the way. and now they are finding it hard to decipher the what led him to leave our unit in the 1st place. here's a clue sherlock: he requested to leave. she also went on to say how she will help in anyway she can but will not jeopardize her job for mistakes on the nurse's behalf. at the current time, things are up in the air and her job doesn't look too much intact.

in the end, this is why i go against the grain and follow my first mindset. i never switched to their demands. i make the full notes on admits and such, but i document only what's necessary, i.e. status changes, dressing changes, physician alerts, etc etc. i refuse to document in a zillion and one places every 2secs. cover your own a$$ but still leave some room for air.

[Piglet08]

Now that we have a computerized charting system, and "all you have to do is point and click!", the amount of data we have to enter has skyrocketed.

And much of it is plain foolishness. For example: pt has a PICC line. We document location of PICC: say, left brachial vein, and the condition of the site, whether it flushes and gives blood return, and much, much more. Then, when we reach documentation re: the PICC dressing, we are asked to document the location of the dressing.

Really?

Yeah, I'm a wild woman. You never know where I'm gonna put that PICC dressing.

Umm, how about ... where the PICC is?