Why is charting so difficult and time consuming? - page 2
What, exactly, is involved? I'm hoping to be a student in a nursing program this March. I have two aunts that are RNs and I've been driving them nuts with all my questions! Now, I'd like to drive... Read More
Jan 9, '07Joined: Nov '05; Posts: 499; Likes: 71Blame it on our litigious society. I chart by exception.
Jan 9, '07Occupation: HomeHealth Case Manager Specialty: 4.5 years Med/Surg, currently HomeHealth ; From: US ; Joined: Sep '03; Posts: 1,043; Likes: 712If you dont chart something, its the same as if you didnt do it. If the patient decides to take you to court and you tell them that you did a dressing change at a certain time and you didnt chart it, well legally you didnt do it. I do not chart each time my pt c/o pain because we have a flowsheet just for this, although I do chart the first complaint and what I administered, then just chart "please refer to pain assessment flow sheet and MAR for further details of c/o pain". We use focus charting. I always chart SOMETHING at least every 2 hours, even if its "pt resting with eyes closed, no acute distress noted, o2 sat 98 on 2 liters NC. Will continue to monitor" This at least shows that I was in the room and checked on them.