So the facility I work for is now requiring that night shift finish our documentation by midnight bc if we don't "it looks like we're not documenting". This irritates the crap out if me!!
#1 We can't chart until we've done our treatments, so how are we supposed to complete a whole shift's worth of work in less than 6 hours? Our HS Med pass is not huge but it's heavy.
#2 Why do we have to finish our charting by midnight when day shift often stays after their shift has ended to chart? I realize that day shift is more hectic, but come on!
#3 Residents who we have to chart behaviors on may not have behaviors before midnight but often will after midnight.
This isn't skilled charting. It's similar but not for skilled purposes. My shift is 1800-0630. I never chart in things that haven't happened, and will not. These notes are more like assessments, but it's still ridiculous in my opinion to want this done by midnight. Of course I assess all of my pt at the beginning of my shift but this doesn't mean I have time to chart the assessment before midnight. The nurse to pt ratio is usually about 30:1.
This isn't skilled charting. It's similar but not for skilled purposes. My shift is 1800-0630. I never chart in things that haven't happened, and will not. These notes are more like assessments, but it's still ridiculous in my opinion to want this done by midnight. Of course I assess all of my pt at the beginning of my shift but this doesn't mean I have time to chart the assessment before midnight. The nurse to pt ratio is usually about 30:1.
Oh within 6 hours a shift change assessment. I think that's reasonable.
So why can't night shift's charting count for that day?
Great observation on your part. One reason may be that, rather than considering the actual date of a note, some places are stuck, as noted previously, on the belief that night shift is 'yesterday's last shift', rather than 'today's first shift'?
Oh within 6 hours a shift change assessment. I think that's reasonable.
Kind of. I get done with report at 1830-1845 and start my Med pass. I have a large 2000 Med pass and a small 2200 Med pass. That leaves me 2 hours at best to complete all of my treatments AND charting.
Medicare (or Medicaid or whatever) apparently requires your facility to chart a note on everyone qday. So, they decided days would do half the residents and nights the other half.
I guess they want the note "timed" before midnight so its on that day (the day you come in).
Fair enough.
Seems like they're confused about third shift. I've found that many day-shift managers are easily mystified by what day is what when it comes to third shift. I had one manager who giving report to in the AM was like an Abbot and Costello "whos on first" bit.
"when did this happen?"
"last night."
"yesterday?"
"No, tonight, I mean last night. THIS last night, not LAST last night"
and so on... :)
If they really need that note before 12am, just chart a note about what happened up to that point. As other "noteworthy" events happen after midnight you can chart those accordingly. That way facility protocols are met and you're not falsifying documents.
Our facility has every shift do medicare documentation. 1 medicare resident for example will be charted on each shift which includes vitals ( yep, that's taking vitals on each medicare resident 3 times a day - or falsifying the info when entering them cuz you had NO time to take vitals in 6-8 residents plus provide the rest of their care) and then answering a questionare on behaviors such as "patient understands verbal commands: a. Usually understands...b. c. d . Ughhhh
Our facility has every shift do medicare documentation. 1 medicare resident for example will be charted on each shift which includes vitals ( yep, that's taking vitals on each medicare resident 3 times a day - or falsifying the info when entering them cuz you had NO time to take vitals in 6-8 residents plus provide the rest of their care) and then answering a questionare on behaviors such as "patient understands verbal commands: a. Usually understands...b. c. d . Ughhhh
Yes, this other documentation I'm talking about is in addition to our Medicare charting!
Here.I.Stand, BSN, RN
5,047 Posts
^^^ and that is if the pt isn't having a status change.