Do more forms = better pt. care

Specialties Geriatric

Published

Does anyone think that the more forms we fill out and the more documentation that we do actually improves pt. care? If so how? In my opinion, decreasing the pt. to nurse ratio, and providing good training to the staff has the greatest impact. Do you think that people are more convinced if the paper work is all in order that the care is being provided or are they more convinced by looking at the residents general condition? What do U think?

Take it from someone who deals with the paperwork!!! Of Course NOT!!!!!

But because we've become such a litigious society, there has to be documentation of everything to simply cover our butts, both financially and legally. I do not, however, condone double charting. Once documented in the chart is sufficient. It is a lazy person who won't look elsewhere in the chart for the information.

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ask the lawyers.

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i agree that charting plays a big role from a legal standpoint. years after an incident takes place it might be the only evidence left. but i dont see a connection between great documentation and forms and great patient care. in most facilities they have peeps doing the paperwork that do not provide patient care, like they are just administrative nurses. :rolleyes:

ask the lawyers.
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I don't believe in unnecessary charting or duplicate charting. I do think sometimes forms help nurses to document important information in a quick way. Our company doesn't require monthly summaries for instance. We do acute charting, MDS charting and incidental charting. Sometimes just getting the opinion of the nurses who actually use the forms helps to modify the form to fit the need instead of creating a new form. For instance, in my facility we want to do a better job of pain control and documentation of a pain assessment. So, we simply added a pain monitor to the MAR that only requires a number from 0-5, instead of a new form. Nurses need to work smarter, not harder. (one of my favorite sayings, don't know who said it originally, a nurse, I'm sure). I have had to review many charts this year for litigation and though we gave good care, great care, in fact, every chart could have better documentation to prove it. So, documentation is always and will always be a challenge.

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Specializes in Cardiac, med/surg, ICU, telemetry.

How many times have you had a patient complain that they had just given all that information to the ER staff. Sorry, but JACHO wants to know if you have any spiritual needs, can u read and write, how far did you go in school, do you feel safe at home, do u use recreational drugs, like they will admit it. It takes an hour to get a patient admitted. Then maybe, just maybe, your meds will be waiting for you to adm. This is just getting my blood pressure up, time for me to go to bed, grumbling about it doesn't solve anything.:uhoh3:

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validating our feelings about the situation is of some benefit. and maybe knowing that we are not the only ones who feel this way. i agree the questions asked on these forms do not benefit the patient or staff. i love the question about the level of education. like what difference does it make? jacho duplicates the nurse practice act and state and federal guidelines. how many different times and different ways can all these agencies and forms say the same thing??? any suggestions to reform this process??????:o

how many times have you had a patient complain that they had just given all that information to the er staff. sorry, but jacho wants to know if you have any spiritual needs, can u read and write, how far did you go in school, do you feel safe at home, do u use recreational drugs, like they will admit it. it takes an hour to get a patient admitted. then maybe, just maybe, your meds will be waiting for you to adm. this is just getting my blood pressure up, time for me to go to bed, grumbling about it doesn't solve anything.:uhoh3:
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Does anyone think that the more forms we fill out and the more documentation that we do actually improves pt. care? ............................................... What do U think?

I do not think that it really improves patient care - unless the paper work is totally relevent to their immediate hands on care, and in the form of a tick sheets or the like. Over the years (I am talking about 20 - 30yrs) more and more paperwork has been added to our work load as RN's but no extra staff has been added, but we still are expected to give total care. I have worked in a few places over the years where there has been a ward clerk that does complete a lot of the routine stuff. Unfortunately most places in aged care I find they do not have such a luxury!

Care plans now getting more and more detailed? Who for? (Hav'nt seen many clients/patients reading them and approving them!) And because of the time taken to write out these plans less time is there to implement them - and there is therefore less time for the other staff to read/refer to them. I am sure that a lot of our present paperwork is great, but who is it for? We all seem nowadays to be drowning in paperwork.

(I retire soon and so look forward to an almost total paper-free life! Even pay the bills electronically.)

Good luck, and please if you all have to knuckle down and write - then make it ledgible - not like some of the 'other' professionals!

Mister Chris. :uhoh21:

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