nursing and paperwork; what paperwork?

Nurses General Nursing

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Specializes in babysitting.

i'm hearing alot of ppl talk about tons of paperwork in nursing, what are they talking about? i've known ppl to drop out of nursing (including a relative) because they said it's too much paperwork. are they talking about those care plans where all you have to do is write the pt personal info. and then your nutritional recommendation? that doesn't seem that hard.

Specializes in acute care med/surg, LTC, orthopedics.

If/when you become a nurse, you will understand what everyone is talking about.

Specializes in Tele/cardiovascular stepdown.

The majority of my job is charting. I don't necessarily call it "paperwork" since a lot of it is electronic, but it's mostly about charting. Assessments, nursing notes, checking other people's charting, checking doctor's charting, making sure every little thing that you do is documented somewhere. It's not "hard" really, it's just a lot of it. One of my professors always said: If you don't chart it, it didn't happen!

Specializes in Med/Surg, Geriatric, Hospice.

I promise you, those care plans are not what they are all talking about.

Specializes in Med/Surg, Ortho, ASC.
If/when you become a nurse, you will understand what everyone is talking about.

OP is not in a nursing program.

So much of it is covering your butt charting. I'd rather have more time to do the assessments and interventions that I have to chart about.

Specializes in acute care med/surg, LTC, orthopedics.
OP is not in a nursing program.

Oh yeah, that's right.

Yet another oddball question not really deserving of an appropriate answer.

Specializes in Med/Surg.

*Smiles to self* My longest care plan in nursing school was 56 pages and if you didn't get it right you failed out of the program and got torn a new one. Not to mention your test that Monday on eight chapters with the chapters being about eighty pages of difficult material. And then there's the project that's due and pre-cal test that if you don't pass you will also fail out of the program. Easy peasy! And I am not exaggerating.

I would still rather deal with the bull crap of nursing school than the bull crap of actual nursing. And yes, there's a ton of useless paperwork to take away your time from actually providing patient care.

Care plan? I haven't had to do one since nursing school. In the LTC we had pre-printed ones and in my current job it's generated by the computer; not that anyone looks at them. :rolleyes:

No, the paperwork is all the redundant charting you have to do.

Take my job for instance.

I have a caseload and I have to do quarterly assessments for about 40 patients every month. Now everything is computerized at my job but I still have to find charts to document stuff on patient teaching records (which I already documented when I wrote my quarterly summary in the computer). We also still do our admission assessments on paper. Before you would just do everything in the chart and now you have to document in both and charts are hard as hell to find where I work. When you have CASACs, RNs, MDs, PAs, Clinic Managers, etc to infinity needing a chart you can spend half the day calling around and running from office to office to find one.

It's a serious time waster to have to scrounge around for a chart to document that you read a PPD when you could have just put it in the computer.

Another brilliant idea, likely made up by some CEO, is to make the staff responsible for billing.

So now we have to document (in the computer) the type of service provided to the patient...write a corresponding note that justifies the service, and then fill out a paper form saying that we did all of that on the computer.

This is just some of the documentation we have to do. We also have to deal with charting for non-billable services; reinstatements post jail/hospitalization, or just missing etc.

This is just the charting part of my job and I think I spend more time on it then counseling the patients or medicating them.

I work in substance abuse so I'm sure the medical nurse’s experiences are different but I have to do a lot of redundant charting.

Specializes in Gerontology.

Charting - everything you do. Documentions of meds - given/not given and why?

Assessments - MDS, RAIs FIMs, HOBICs (I know none of these will make sense to you, but trust me, they take a lot of time and energy and must be done.

Requisitions - I can't get anything without what seems like 10mns of paperwork. If my pt want a sandwich instead of their entree, I have to put in a requisition.

If a light bulb burns out, I have to put in a work order to get it fixed.

We don't have a unit secretary after 7:00 pm on weekdays, and none at all on weekends so nsg has to do it!

Aren't you the same person who did not see the importance of keeping a sterile field even though you were in scrub tech program? Now you want us nurses to explain to you what we chart about when you have already decided what it consists of.

Specializes in Family Medicine.

Step into the light johnnyDoGood.

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