Help with Charting

1. Narrative

2. Leaving out things they did. (If it wasn't documented, it wasn't done). Not following up after change in status during shift. (Temp 101.5, Tylenol given for fever....never documenting afterwards the results after Tylenol given). Documenting things that don't belong in the patients chart. Charting themselves or others into possible legal issues (5 hours in to a shift documenting last shift left feeding pump set at 45 mL/h and I'm now noticing it and changing it back to 90mL/h per orders) Documenting opinions. Wording of documentation.

3. The schools need to hold classes specifically to teach documentation and the legal side of it. Also schools need to teach what the reader of the nursing notes is wanting. In PDN I know that medicare will be reading my notes and deciding on how many hrs the pt needs. So I make sure to show EVERYTHING I've done and I document that the family is gone when they are working to show need. When I was in nursing school they focused so much on what not to do, that they failed to show what to do. They would tell us the if it wasn't documented..... But I never saw a "real" nursing note to see what it was supposed to be like and the rationale for the statements in the nursing note. I never saw a statement that could get me in to trouble vs the statement rewritten to avoid trouble.

I took a legal documentation class by a nurse/lawyer. Excellent cont. ed class that changed my documentation forever. I reccommend it to any new or experienced nurse.

Thanks for your time...:redbeathe

flow sheet and narrative

horrible spelling, narratives don't match flow sheets, not sticking to the facts, poor

word choice

I just read SDALPN's post, she said everything I was going to say, only better.

I also took a legal seminar and again SDALPN is spot on.

I'd love to see a nursing school and a law school have students role play where the law students would try to take apart nurse's documentation.

1. We use a computer charting system. Its a mostly selecting the aprotprite assessment from a list with option to annotate side notes for each system.

2. Spelling, times not lining up (ex. Time stamp of charing is 2000, but writer says med given at 2100)

3. Hmmm.....a spell checker built in would be nice. Easy to use systems. The one we have now is great; it’s hard to make a mistake. All charting by exception, no double charting. A lot less mistakes then at other places I have been.

Love the idea of role play. But not so sure I want the lawyers to get better at tearing apart nursing documentation. :-) I think most of them hire legal nurses for that now.

1. EMR. For our assessment flowsheet we have drop down boxes and we just click everything applies. For each body system there is also a box where we can write a little narrative note if needed. We have other places to write narrative notes in the EMR if needed.

2. Atrocious spelling. Not documenting (again if you didn't document it, you didn't do it, even if you did!). I always review the charts from the previous shift and some nurses barely document...it scares me As SDALPN mentioned, documenting things that don't belong in the patient's chart and putting you/others into the chart.

3. I think legal documentation classes are an excellent idea. We went through documentation in my nursing program, but never really went over the legal aspect of it.