I Chart Too Much?!

Nurses General Nursing

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My coworkers are always joking with me that I chart too much. It doesn't take up more time, I just chart everything I do. I have several jobs and at one job, for instance, I have two high acuity patients. Every time I do something with my patient I chart it. It is paper charting and I write very small. I can easily have a page and a half for each patient. A few of my coworkers may wait until the end of their shift to chart on everything. Some do as I do. After I preform a procedure, I chart.

Co-workers also joke with me at my other job. It's computer charting and I chart a summary after each patient. They will jokingly say, "I want that book signed when your finished."

Okay, here is my concern. Whilst in nursing school my instructor told me not to chart so much, that I could legally get in trouble should anything happen. I also know from common sense that "if it isn't charted it isn't done". I just chart the facts, nothing else. I chart what state the patient was in before I preform a procedure, what procedure I did...per orders, and what the outcome of the procedure was. I chart every hour on a patient sometimes when it is only required to chart every 2 hours but I just chart every time something is done....etc.

Specializes in Oncology.
Duplicate charting got us into trouble more than once, there's too much opportunity for duplicate charting not to match in some miniscule way, but that's all it takes for a lawyer to find an opening.Another was a situation that became both a civil and criminal case. A patient sued due to a fluid restriction order. It wasn't apparent at the time that he was upset about the fluid restriction, although he was suffering from some delirium. For whatever reason, a Nurse put "patient offered water, patient declined" in her note, which their lawyer then used to argue that the Nursing staff charts whenever they offer water, and since this was only charted once, it was argued (successfully) that during his entire stay the Nursing staff had only once offered the patient water. It was true that we weren't giving patients sufficient opportunity to refuse a fluid restriction order, but some unnecessary charting which was thought to be harmless at the time ended up making some practice issues appear like intentional systematic abuse.
So if another nurse charts how they're offering water and I don't, does that make me look negligent in the above case, or not so much if I never set that up as my charting standard?
Specializes in Emergency, Telemetry, Transplant.

First, I don't think it is accurate to say a nurse charts "too much." The question becomes, is all the charting appropriate and accurate? Does it give others and accurate picture of the patient or is it just a bunch of random observations that gives the perception of inadequate attention and care? Is it unbiased and factual or is their a connotation to the charting that paints the patient, family, or other staff members in a negative light?

Writing a detailed note on a procedure is appropriate, charting a problem (such as SOB) with an intervention and an evaluation is appropriate. However, charting the same data in two places is not a good thing. Sometimes the charting systems require it, and care must be taken to make sure the time and data are the same in each place. As already mentioned, inconsistencies will get you.

A few examples I have encountered:

When I was a new nurse, there were students on my floor with their clinical instructor. A student went in to see my patient and part of his note included the phrase "adequate fluid intake." This note was written in consultation with his CI. Well, obviously the note is not very good to begin with. This is just one of the silly 'platitudes' that nurses like to use in their charting (another would be "no c/o at this time"--I really dislike this one...sorry, I digress). The other problem with his charting--the pt underwent HD three times per week and was on a strict fluid restriction. My guess is that his instructor wanted him to address fluid status in the note and found this meaningless line did just that. Can you imagine what would happen if this pt had some sort of acute fluid overload situation and this pointless line was in a nursing note? I guess the plaintiff's attorney would not find it so pointless.

Another example that could be risky: we use a EMR with an eMAR. There is one nurse who would write a note "IV push med given per eMAR" or "IM medication given per eMAR." Obviously when you 'sign off' a given med on the eMAR it is charted. What were to happen if she did not time her little note to the time she actually gave the med on the eMAR? Suppose she went back to chart her note later. Say the med was given at 1930 (and charted off at that time). She gets her 24 hour clock wrong in her mind and charts 1730 (I know I have done this before...chart 1730 when it is 7 pm...ugh). What if the pt has a reaction to the med? What is the correct time it was given? I make look like it has been 2.5 hrs after giving the med before she rechecked the pt rather than just 30 minutes, based on her (what appears to be harmless) note.

There are certain clichés in nurses notes that I hate, too. "No voiced complaints", I never chart this. I always put pt *denies* pain or nausea or SOB or whatever. This shows we actually, you know, asked. It shows we *know* they're not painful, not just assuming they

aren't because they didn't say anything.

Also, where I work, we're encouraged to chart a note for every little everyday behavior issue.

And our policy is to let the CNAs chart in the nurses notes. So we end up with page long notes about how Miss Ruby refused her HS care or was impatient or something. Most of these come across as very judgmental. I cringe to think what would happen if these notes make it to court. Any decent prosecutor could easily paint the picture that we plain didn't like these resident and thus provided substandard care. By letting people ramble on and on about every little pt care issue, we're just creating more potential rope to hang ourselves with.

Specializes in Emergency, Telemetry, Transplant.
And our policy is to let the CNAs chart in the nurses notes. So we end up with page long notes about how Miss Ruby refused her HS care or was impatient or something. Most of these come across as very judgmental. I cringe to think what would happen if these notes make it to court. Any decent prosecutor could easily paint the picture that we plain didn't like these resident and thus provided substandard care. By letting people ramble on and on about every little pt care issue, we're just creating more potential rope to hang ourselves with.

I don't think allowing CNAs to chart in the NN is a good idea. And I am not tying to get into a urinating contest (i.e. they are not nurses) over this. If that document (the NN) is going to be used in court or some other public forum, the person who writes the note need to be trained and experienced in how to write a germane, factual account of what happened. I would fear that it would, too often, become a chance for CNAs to get "payback" because some resident's behavior upset them.

Where I was a CNA, we had a section in the CNA charting book that had a sheet for behavior issues. In the first column you listed, by number the "behavior" (1 = hallucination, 2 = refused ADLs, 3 = combative with care, etc.). I the next column you charted, but number, your intervention (1 = redirection, 2 = diversional activity, 3 = notified nurse, etc.). In the last column you listed the response. That way there was no way that someone without charting experience could chart something really foolish, such as "Mrs. R combative with care. Told Mrs. R she needed to behave herself. Told Mrs. R that she was going to sit in her wheelchair in the bathroom for 5 minutes before I came back and we would try this again." Yes, this not seems somewhat unrealistic, but I worked with some CNAs that were crude enough to do this and stupid enough to put it in the NN.

It's weird because everyone says how horrible double documenting is, but our system is set up with so much double documenting built in it's insane. For example, you chart a pain assessment with vital signs, with your nursing assessment, and again on the opiate drip flowsheet if they have a drip of some sort. That's just once example.

As someone who reviews charts for a good part of my living, I LOVE double documentation. You wouldn't believe how many people chart totally different things on the same patient, all on the same day. And then someone else charts another thing entirely. Sometimes I say, "Two outta three?" and sometimes I say, "These people are so screwed when this gets to the lawyer." And even, sometimes, I say, "Good for you, this all matches."

Tell the story accurately and you never have to wonder what happened when confronted with two different ones, both with your name on them.

Specializes in Med Surg.
I just chart everything I do. I have several jobs and at one job, for instance, I have two high acuity patients. Every time I do something with my patient I chart it.

You'll have to forgive me since I'm new (as in still a student), but I thought that was rather the point. If you don't chart it, then it didn't happen, and what have you.

Specializes in Med/surg, Quality & Risk.
It's weird because everyone says how horrible double documenting is, but our system is set up with so much double documenting built in it's insane. For example, you chart a pain assessment with vital signs, with your nursing assessment, and again on the opiate drip flowsheet if they have a drip of some sort. That's just once example.

HCA!!!!!

Excessive charting; no such thing. This is the legal record of everything we do.

--- 2200 Pt resting quietly in room with eyes closed, R 12, no signs of distress (this is where some will put will continue to monitor, but they never say what they are monitoring, so im not gonna do that).

0300 pt found on the floor in room, unresponsive, airway patent, R12, P90, Bp 110/74, O2 administered per Nasal cannula@ 2 Li/min. Arranged for transfer to XXX unit for further evaluation, POA notified. Dr. XXX notified.

Frivolous charting would be telling me things I do not need to know as the oncoming nurse delivering this client's care. I have seen charting that went into a 'and his nephew is angry.." and alot of other details that are absolutely irrelevant to the patients care.

I want to be able to read what has been done, so I can further judge what to do. I do not want to read some fairy tale about irrelevant things - had a LPN coworker who thought the notes were a place to record interpersonal observations but not specific to that patients care.

This used to really get to me; I dont really need to know that.

Specializes in Acute Mental Health.

I took a course on charting to keep you out of the courtroom and I do recall being told that yes, you can chart too much that can get one into trouble. We were taught to state the facts but don't chart every single thing. If there were to be a court case, you have nurses working for the lawyer who go directly to the nurses' notes and begin picking everything apart. The instructor for the course was one such person. She would take hours to make a huge chart of what was done at what time and what day. She then would compare it to the docs orders and notes. It's a huge process and so many things can be pieced together that it's amazing some don't win in court. There are books available you can buy.

If you get a chance to check out a course like the one I took, they are offerred around the country yearly. I took mine through Pesi

Specializes in Oncology.
HCA!!!!!
What does this mean?

Hospital Corp. of America

Specializes in Emergency Department.

Way back when, I learned NOT to doublechart whenever possible. Back then, we used paper to chart on. I used the narrative to paint the picture of what the patient "looks like" and any check-boxes or other data fields to record stuff, and simply reference those data boxes in the narrative if it becomes necessary. Saved time and left room on the charts for additional documentation if that became necessary. In the EMR system that I was using this past Fall semester, I just adapted the way I paper chart to the EMR. You just can't easily paint a picture of what the patient looks like when you're using check boxes and fill-in forms. So that's what I just use the narrative for. If I do something for the patient or assess something that isn't routine, there's going to be a note in the chart about it, somewhere. And yes, I do chart as I go along. It makes it soo much easier toward the end of the shift when you only have a couple things to note in the chart because the rest of it's pretty much all done.

And yes, it's possible to over-chart... The more you write, the more likely it is that you chart information that contradicts something else in your charting about that same patient. So, just be more concise and only use approved abbreviations, if you use them at all, and make sure that your narrative times match up with the times in the rest of the chart. The other thing I learned is that there are certain scripts that I use to lead off my charting. Makes things a whole lot easier when I know how to start instead of trying to figure out what I want to say to begin with. I'm still learning to adapt that part of my narrative from paper to the EMR narrative, but it makes things go a bit more quickly.

I absolutely despise charting. It's the bane of my existence. I would much rather do the patient care than do the charting... but because "if it's not charted, it wasn't done" really does occur, I have to be as good at charting as I can be. After all, you really never know when you might be hauled in to testify about care you gave a patient that you really don't remember because it was that long ago. All you're going to be able to work from is the charting that you did.

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