Many nurses do not chart?

Guest716906 · Dec 7, 2017

I'm all over the map on this one. I see nurses at my workplace who are seated at the station, ready to give report and count narcs at 15 minutes to shift change. I used to wonder why I wasn't that fast. After my patients got to know me, they would tell me things like, "You're the only one who gives me my eye drops", or "You're the only one who checks my dialysis shunt". I had one blatantly ask me why no one else gives her her medications. I wouldn't throw another nurse under the bus, so to speak, but I'm no longer impressed with how "fast" certain nurses are with their med passes. As far as charting goes, I have to agree with the originator. Some nurses don't chart. Period. They will give you important information in their report, but nothing is ever charted. Or if you ask questions about a certain patient, you'll probably get a response like, "Oh, Mr. So and So? He does that all the time. He's just that way." I don't chart excessively, but I'll certainly chart to show that I noticed something, intervened and either got the desired outcome or passed the information to the oncoming nurse so he/she could monitor the patient. CYA. I'm convinced no one else will.

That happens to me a lot as well. Last night I did mNIHSS every four hours with my patient. She asked why and I said we check q4 hours for stroke patients. She thanked me and said nobody else had done that with her. (?)

Guest716906 · Dec 7, 2017

I haven't been a Med/Surg nurse in a while because I'm in the ED now and the charting requirements are completely different but my previous nurse manager regarded me as a pretty thorough in the documentation department and I didn't have to stay late in a shift to document very often. Here is what I used to chart on my patients during a given shift:

Thank you.. this was very helpful. Do you like ED better than Med Surg? I'm ready to leave med surg/tele ASAP.

Guest716906 · Dec 7, 2017

I took a class a while back on Legal Medical Documentation. I learned a lot about charting. When 2 much charting is just as bad as not enough. As a nurse most of us know what is crucial to patient care and what the Physician will be looking for when he reads the chart. It would be helpful to take one of these classes if you can. I stay in touch with the lawyer who taught the class and it is amazing the errors she finds in charting that helps her win her cases.

Please give me some more info if possible? Where can I find these classes/ what class did you take? I think just a class would fix my problem so I would know exactly what is necessary and leave out the things that don't matter.

NurseBlaq · Dec 7, 2017

You are right, nursing school teaches nothing about charting. And I am recent graduate (May, 2016).
We spent time learning how to do hospital corners (with sheets), even though hospitals use fitted sheets, but no time on charting!

One of my professors was also an attorney who specialized in medical malpractice. She told us to "chart like you're going to court" so I do. Things others may think is excessive may save your career one day. You won't remember what you did for XYZ patient 6 years from now if something came up. Add to the fact people are sue happy and nurses are the lowest on the totem pole to catch blame cause facilities protect doctors and supportive staff don't have a license to lose and haven't struggled through nursing boot camp. I trust nothing and leave out nothing. I've worked with enough snakes, especially wicked NMs, to leave anything to chance. Chart as you see fit cause it's your license!

OK off my soap box, ugh. LOL

Having said all that, be cautious not to chart personal opinions or anything that will get you dinged later. There is a such thing as too much detail in medicine. Maybe try getting with your facility's education dept. and ask for their input or some tips.

Guest716906 · Dec 7, 2017

One of my professors was also an attorney who specialized in medical malpractice. She told us to "chart like you're going to court" so I do. Things others may think is excessive may save your career one day. You won't remember what you did for XYZ patient 6 years from now if something came up..

100% agreed. How high are the chances of going to court/losing license/getting sued? I'm scared and confused. I wish we learned more in school ðŸ˜

NurseBlaq · Dec 8, 2017

Not high unless something major happened or there's a family member who just won't let go. Her rationale was if an attorney or medical expert can read your notes and get a picture of what you did for that patient then they won't need to contact you. She said the worse thing for a nurse is to be in a courtroom and have your notes up for all to see and you can't explain it. Cause you know the saying "if you didn't chart it, it wasn't done." She said you can't explain it later cause you didn't document it. She also said you're more likely to not remember cause look how many patients you will have taken care of over the years. The only patients most of us remember are our favs, our less than favs, and those who said something that made us laugh & remember them.

Guest716906 · Dec 8, 2017

Not high unless something major happened or there's a family member who just won't let go. Her rationale was if an attorney or medical expert can read your notes and get a picture of what you did for that patient then they won't need to contact you. She said the worse thing for a nurse is to be in a courtroom and have your notes up for all to see and you can't explain it. Cause you know the saying "if you didn't chart it, it wasn't done." She said ..

Thank you! That helps a lot :)

jodispamodi · Dec 9, 2017

What type of charting are doing?, an admission assessment or a focused assessment? Are you writing comments after each entry? Are you writing a lot of notes? Are you charting throughout your shift or do you do it all at the end?

Honestly, I doubt other nurses are leaving charting undone, esp. if you work in acute care- auditors and risk management would have been on their backs about it by now. I once worked with a nurse who appeared to be charting all night long, then when report came she would grab a cow, bring it to report, then continue charting after report was over, there was nothing that happened on our shift that required that much charting, so I now wonder if she was just trying to get some OT as she was per diem, anyway I digress.

Take a look at what you are charting, if you have a patient who came in with a broken leg, you should focus your charting around the broken leg, and if his ls, bs, and etc are within normal limits, you should just chart wnl. If something is off, you hart that as well. Are charting on the care plan? Are you getting overly wordy on that. I know management likes to have a beautiful narrative in there for cms, but honestly for me, for the patients chief problem I will write one sentence, then the rest I usually just document progressing, no change, etc. If they would like me to chart a beautiful narrative, they need to give me less than 5 patients. As far as notes, if the patient condition changes, and the team needs to be notified I write a note to cya, if the patient condition changes, say had rhonchi but cleared after IS use I document that in the assessment. I also try to batch my charting. So if I go in the room to gives meds, ask the patient his name, dob, how his pain is, listen to his lungs, and bowels, I can chart on all that while I'm still in the room. (and if I need to page the team I document that as I'm paging them,) and for the rest of my charting I try to do it in between med passes, dressing changes etc. On the days when I've been insanely busy and unable to chart much, I start charting before giving report, and while I'm waiting for the next nurse to come, rarely do I stay late because of charting. I

If you have friendly coworkers, you can always just ask them if they can give you any pointers for timely charting. Although again, I suspect they are doing focused assessment/charting.

Good luck.

sunny time · Dec 9, 2017

I've seen some pretty good chart as a chart review nurse. so good in fact, that it makes me wonder if all the things that were charted were actually done. nobody has that much time in an 8 or 12 hour shift. especially, if there is a glitch in the day.

BeachsideRN, ASN · Dec 10, 2017

I think I am realizing that we learned nothing about court/defensive charting/ the legal system in my nursing school. I used to just chart what I thought was relevant. As the years go by, I have gotten dinged for things/managers keep adding small random things we "have to chart". Makes me wonder have I been doing this wrong all along? Why do they make a big deal out of this.. aren't focused charted assessments more important? (Frustrated)

Nope. But CMS has changed the way they reimburse. That's why there are things that must be charted (like turns, pressure ulcers present on arrival os, etc)

Reyn04, MSN, RN · Dec 10, 2017

Perhaps its a time management issue?

I chart regularly throughout my shift & rarely leave late & have never been "dinged" for charting through 5 hospitals both paper AND electronic. I do a final chart check 30-45 mins before incoming shift (time permitting, but always before I leave). I've worked ICU (2:1), PCU (3 or 4:1), Med/Surg (5 or 6:1), Procedural (4max :1) at times with being Charge or a clinical teacher to 2 & checking their charting. What I'm saying is I've experienced a lot of different scenerios & census ratios. I stay late on rare occasions but as a rule am out on time.

If you're staying late nearly every day, something you're doing or not doing is not working. Find someone whose charting is complete & appropriate & who leaves on time & maybe get a tutorial? Or talk to staff ed/ informatics for a charting review and or streamlining discussion.

NurseNinja1990 · Dec 10, 2017

I just learned some keyboard shortcuts that really cut down on my charting time. That, and videogames have made me a fast typer lol

Some examples: TAB to go to the next section, and SPACE to select the first option. Alternate SPACE and TAB and you can fly through the chart under the sections where you found no abnormal assessments.