I Chart Too Much?!

[skittlebear]

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.

[RNperdiem, RN]

Wouldn't it be nice to chart only enough to communicate needed information needed to take care of the patient?

I have a collection of vintage nursing books and books about nursing. The patient chart is little more than a clipboard at the foot of the bed.

[Altra, BSN, RN]

This thread highlights a few recurring themes:

1. Documentation systems often contain redundancies - the same information is required to be noted in more than one location. In my experience, the wording of the various "check boxes" often differs slightly, creating opportunities for conflicting data to be documented.

2. Electronic documentation, particularly the "check box" variety, often fails to "paint the picture of the patient". Excessive detail does not necessarily communicate the progression of care provided.

3. Charting "defensively" can focus on offsetting potential patient/family complaints as much as forestalling possible future legal review.

[Pepper The Cat, BSN, RN]

Yes, I think you can chart too much.

Here is an example: I had a pt who had a total hip replacement. One am she complained to me of increased pain. She said she thought she might have twisted it during the night. I documented "Pt c/o increased pain to lt hip. States she thinks she "might have twisted it during the night". MD informed, Xray orders rec'd ". Later I added a note that the Xray was normal.

The next day, I find a note from the nurse that had the pt on the night that she said she thought she twisted it.

It started: "Pt asked to go to BR on X day. Assisted to sit at edge of bed. Did not twist hip. Assisted to put slippers on - did not twist hip. Assisted to stand - did not twist hip.... - it went on like this for 3 full screens of charting. All in capitol letters. We were all reading it and laughing it was so riduculous. It came off as defensive.

[joanna73, BSN, RN]

For legal reasons, and as per your facility policy, we are required to keep accurate records. However, a little common sense goes far. I try to remember this: Am I charting for the patient, or am I charting for myself? Documentation should be pertinent to the plan of care, and concise.

[mikeanthony81]

Keep charting the way you are and don't let anyone else put you down for it. You may find that in 10 yrs you still have your job an others don't for that reason alone.

[hodgieRN]

Keep charting the way you are and don't let anyone else put you down for it. You may find that in 10 yrs you still have your job an others don't for that reason alone.

I was thinking opposite.

[skittlebear]

This was meant for a quote :-)

[skittlebear]

If more than one person is telling you the same thing, then you need to look at it more carefully. If you are putting in extraneous information then that might come back and bite you some day. Just chart the facts. Also, could it be you are charting to keep from actually doing something else? I worked with a nurse who wrote a tome on each patient, but was too busy charting to really get her work done or help the rest of us with other tasks. She "hid out" on the computer.

Hi classicdame, I actually have more than PLENTY of time to get my job done and charting seems to take up less time than it does others. Maybe it's the fact that I like to write. Words come easy to me. I don't know. I am not saying I'm a grammatical queen by far. In fact, I'm sure you can pick out many grammatical mistakes in my posts. I actually have time to do my job and help with others' jobs as well. I am PRO teamwork and when I am clocked in this is exactly how I think: My time is dedicated to the patients I serve. They are paying me (through my employer) and my time is theirs. I have this in mind every time I clock in. I'm actually pretty good with time management and my charting doesn't affect this.

A co-worker at one of my other jobs stated that charting too much could not land in your favor in court. I have heard nothing but negative things about this co-worker (ie: how lazy she is). Her charting is very, very short and a little difficult to read. She charts big and it takes up only half a page whereas my charting takes up a page and a half and I chart small. The only thing I am charting is everything I've done for my patients for each shift. After I do something, I chart it. This isn't a hospital setting where I work. It's a home care environment. My main job is a facility and I have another agency job. Just thought I would clear things up. ;-)

[FlorenceNtheMachine]

I think everyone is giving good advice. Everything you put out there, may be scrutinized to the fullest extent of some lawyers imagination.

If YOU are happy with it, then nuts to anyone who says otherwise.

But you know, there are a lot of sage wisdom in nurses who have been around the block. Heed it :) it's usually coming from a good place.

[skittlebear]

I am awed that you can "chart to much......it doesn't take up more time.."

Yikes, I wish I could shadow you for a few shifts. I think your way is better than mine.

I don't really like charting, but know I am supposed to keep up, keep current. Yet most days I end up near the end of my shift illegibly scribbling hastily done lousy charting because I can't seem to keep up and keep current.

In my defense, which won't hold water in a court room, because I hate to chart I probably spend more time (to much time) with the patient, at their bedside, even making sure family and visitors are "cared for".

Honestly how in the heck do you do it?

I write everything down the moment I do it. If I don't write it down in the charts immediately, I write it down on my hand, a scrap paper I keep in my pocket, or my notebook. Whatever is the fastest. I then summarize it all at the end of the shift if I don't have time to immediately chart. I don't take breaks unless it's a bathroom break and I eat while I chart. I rarely stay over due to my charting. I always have this thought in my mind when I chart....CYA....CYA...CYA....and the charting just flows.

I will tell you though at the moment I don't have a lot of clients such as you. I have 2 clients in a home care setting and this is the main place I am talking about. I do work 2 other jobs as well though and I just summarize at the end. I have worked in a place where I have had 20 clients. I still did chart quite a bit. Maybe too much for some. I don't know. When I start charting in my notes it just flows. I have no idea.

[skittlebear]

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.

Thank you...thank you....thank you!!!! This is the type of advice I was looking for. :-)

[skittlebear]

A lawyers job is to win their case and they will do everything in their power to make you look incompetent. Now, if you are sitting on the stand with representation, the hospital-assigned lawyer can argue speculation or out-of scope, but during a deposition, you are on your own. Every word you write is a point of possible attack. Don't get me wrong....charting shouldn't be substandard or have anything left out that is pertinent to pt care, but I think if you write too much, it can be used to corner you. The lawyer doesn't care about your feelings, your job, your well-being, or how hard you worked to care for your pt. They dive right into your notes and go fishing. They hire other nurses to pick apart your notes and find inconsistencies. Even if it was a doctor that slipped up in surgery,they try find some way to pin excess blame on you so they can get more money from the hospital during a suit. They are looking for anything that might look like negligence. I chart that I spoke to the family and updated them on the pt's condition and plan of care and the family had no further questions. If you chart that and how the mother was upset or crying, they will come back and say you didn't recognize signs of distress, which mean you and the hospital are liable for emotional damages. BUT, that probably would stand up in court, but during your deposition when you are all alone in your seat with 3 other lawyers grilling you, it works as a great tactic to shake you and make you give up feelings or opinions that can move their case ahead. There's a reason why doctors don't write massive amounts of detail or opinions in their notes. They are taught to give the facts and plan of care or evals. When we use paper charting, I was taught to fill in my assessments and use the narrative notes for intervention/evaluation, unexpected events, or PRN tasks. I never double charted my assessment in the narrative. I did know a nurse that wrote her entire assessment in the narrative and was called to court and the lawyer grilled her. He argued that since she stated everything in the narrative, anything that wasn't in the narrative wasn't done, even if it was charted in the assessment. That doesn't hold up in court, but it suddenly did.... b/c she stated "Everything I do in my assessment, I write in the narrative." He was then able to use her statement against her since the narrative was the admitted go-to for her charting. Nothing ever came of it of course, because it's obviously very thin in the grand scheme of things. But he was trying to get her to admit that maybe everything isn't written in the narrative, which make her look like she was changing her position. It was tiny ploy that only lasted 10 seconds, but a lawyer uses different strategies and tactics to pick at you. Nurses are not educated on legal matters or self-representation, so nurses are the perfect target. " You said this...doesn't that mean something? Why not? How can you say that when you clearly you meant this. Isn't this what nurses are supposed to do?" It's an interrogation. I think you should write what you need to write. Give a clear, accurate description of your pt care including assessments, intervention, evaluations, task, and responses to matters concerning the family and pt. Every word after that will be scrutinized to label you as negligent, incompetent hospital worker. Just my opinion :)

Thank you for this post. We are required to document at least every 2 hours in our paper charts. I do double chart in my narrative notes what my assessments are. I will definitely rethink this after what I'm reading!