Many nurses do not chart?

Irish_Mist, BSN, RN · Dec 14, 2017

I couldn't care less how other nurses chart. I do my best to make sure MY charting is accurate, clear, concise not only because I care about the work I do but for CYA reasons.

My feedback: Who cares how long someone charts, or how late they stay? Worry about yourself and your charting and everything will be golden. I have seen so many people get so outraged about other staff members' charting and each time I tell them that that is not the hill to die on.

Accolay · Dec 15, 2017

I figured charting by exception would be a given. Didn't think it was necessary to be that trivial.

There are a lot of boxes in electronic charting. Some people think you have to make sure they're all filled in.

jodispamodi · Dec 15, 2017

Your facility should have charting guidelines for you to follow. Many places chart by exception so that would include charting only when something goes wrong or is different from your patient's baseline. I have experience as an RN and FNP for over 25 years and I have been serving as an Expert witness for the last 16 years evaluating nursing care in multiple settings and defending nurses to prevent license suspension. I will tell you that excessive charting is not necessary, but your charting is more important in a legal setting that administrations/nurse leaders/professors would like to believe. The average case I receive reaches a courtroom in 3-5 years AFTER the incident occurred. Defending your nursing care by saying "my typical practice" is to do this or do that, does not meet the standard. You will need to be able to show that you adhered to the standard of care by documenting your nursing actions and assessments. I will agree that you do not have to have a narrative for everything and many things we do as nurses can be located in other parts of the chart, i.e. medication records, vital signs sheets, etc. Protect yourself, I have watched many facilities/administrations, etc. completely leave employees out in the cold when they are sued.

The doctors charting on epic is no different, I've often said I'd hate to be an LIP and have any notes come into question because what I've seen at my facility they are all just copy and paste, its useless to try to even read them for floor notes. The only ones that offer (imho) an actual picture of the patient are the ER notes and initial consult notes.

TruvyNurse · Dec 16, 2017

What I find ironic is that I see nurses staying HOURS after shift change in my LTC facility but when I worked on a busy Med Surg floor, Nurses generally left on time. However my LTC facility requires ridiculous assessments (skin charting on a scab that is long healed and not changing) and if you receive telephone orders, it is not enough to get the orders over the phone. You have to fax the doctor to get the signature and rewrite out the order and then chart in the computer and then put the order in the physical chart. I find it ridiculous.

gonzo1, ASN, RN · Dec 16, 2017

I work in ICU. I have followed nurses that didn't even do the initial assessment on the pt. Don't be that nurse, LOL. Your hospital most likely has a P&P for what has to be charted and how often. Find it and learn from it. Additionally, never, ever double chart. If you have documented anything 1 time, 1 place, do not double chart it anywhere else. That can get you in trouble if you go to court. If where you work wants you to chart in two different places on the same thing, do not do it.

There are many books out there that you can buy to learn what to chart, when and how. There are also many avenues for learning how to chart to appease the legal Gods. There are books, seminars, conferences. Google them. NSO posts cases all the time. Look up how to chart on youtube. In this day and age there are many sources you can use to educate yourself. There are also many great ideas already posted. Do chart that you have done baths, treatments etc. When an antibiotic is done chart, "no adverse reaction." if it applies.

It is true that a lot of nurses get done quick because they aren't charting and doing what they should be, but I don't want to be that nurse, and you don't either. One last idea that I only recent started due to coaching by an "old" nurse. Do everything you can early. If a med is due at 2100, give it at 2000. That kind of stuff.

Agatha12 · Dec 17, 2017

When 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.

HeySis, BSN, RN · Dec 17, 2017

I 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.

TitaniumPlates · Dec 18, 2017

Sorry, 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.

AlabamaBelle · Dec 18, 2017

How about watching nurses chart an assessment on a patient they have not even seen yet?

TitaniumPlates · Dec 18, 2017

. 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.

AlabamaBelle · Dec 18, 2017

If 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.

scout mom · Dec 20, 2017

At 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.