Many nurses do not chart? - page 6
Hey, I was just wondering. On my unit I leave late every shift because of charting. The other nurses always leave on time, and they leave A LOT of charting blank. I am realizing that if I want to... Read More
Dec 17, '17When I was a new nurse I was staying longer all the time to finish charting. Now it is really rare, only if something unusually busy happens and I wont make it. I chart a lot, my entries I always much longer than others. I learnt to chart any call to MD, any discussion with family immediately, I never leave charting to the end, I start the earlierst possible and update throughout the day.
Dec 17, '17I rarely have to write a nurses note anymore.. when I started in nursing it was all SOAPIER notes written in a specific color ink to show which shift you were.
The charing system I use now looks like a spread sheet, I tab down the line of boxes and click was is necessary. There are even parts where I can merely click assessed and then unchanged. (like surgical site). I don't have to describe it every assessment.
I chart so that when I look back on it I can remember what I did. I keep my charting consistent, when there are several places I can chart the same thing, I chart it once and always in the same place, that way if I need to look back I don't have to look over the whole thing to find if I did something.. I just have to look where I normally chart it.
If I can read my chart and get a picture of what the patient looked like, what I did and why, then I'm good for court, incident report, family complaint.... IF I see an abnormal result, you should see an intervention charted and then the response. When I give pain meds, I should see a pain assessment and then response. These things can be quick, I check the pain box "yes", place a "number" in the rate box, check the "area of the body" and a box by the description as "stabbing, burning" or whatever and check the box "pharmaceutical given" under intervention. Takes me all of 15 seconds to do it, but I can justify why I gave that med at that dose at that time.
Dec 17, '17Sorry, but why is there such angst about this? Get a copy of the "chart audit" example, what NEEDS to be charted and when....and start from there. Geez. If you can see what you are REQUIRED by your unit to do, then you can see if it's YOU or it's THEM.Last edit by TitaniumPlates on Dec 17, '17 : Reason: added comment
Dec 18, '17<shrug>. Then rock that boat when you see it happening if it bothers you that badly. That charting is done under someone else's license, not yours. If your assessment disagrees with theirs then that will come to light and you have your opportunity to sink that nurse.
This isn't about charting assessments that we're never done , however. OP is stressing because she is always late going home from catching up on what she seems important.
There are basic audit rules and policies per facility. Usually they are common to each. Somway differ with q2 vs q4 or what have you, but basic charting per audit rules is a documented policy somewhere. They don't just expect you to know it by osmosis.
If OP overcharts, that can get her into as much if not more trouble than undercharting. We all have been there too. I chatted a free note that said right foot by accident I meant left bc I was rushed. Just an example that is egregious but you get my drift.
I then went on to continue charting on that properly noted left foot and that one incident of a free note that wasn't even necessary and said right? Gets me in hot water.
Do the audit rules charting and add to it if it is something out of the ordinary. Blathering on in free notes doesn't impress anybody. In fact it ticks a lot if us off because we send our time slogging thru redundant crap.
Learn the basics if your unit per policy. If you feel like staying an hour afterwards to chart that patient had a really nice personality and you brought them candy from the gift shop, go ahead. See how well it goes over when you make a mistake because you just can't keep it simple.
Dec 18, '17If I chart something in one place, I don't chart anywhere else. Too easy, even for the most diligent of us, to make that one slip that makes the whole thing look bad.
Dec 20, '17At my previous job, I worked at a small ICU. We were required to enter a "shift note" every 8 hours at specified times that was a summary of our shift. This was for the doctors who, apparently, didn't want to actually have to look up anything for the shift. Our manager would check to make sure they were done when they were supposed to be.