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.
That's my point. A note started at 2230, and saved 'to complete at 0400', isn't charted 'prior to MN', no matter how you slice or dice it. This is not at all the same things as having an assesment done before MN, and charted later. Other than this, the fact is that once you start something, you ought to finish it- rather than go back later, because you are just wasting time, when in fact the core issue of this point is somehow to 'save time' by starting a note on one date, saving it, then going back (revisiting the same task twice) to finish it on the next date?
Based on my experiences running reports via EMRs, I wonder if this is a non-clinical person running a report that isn't quite right, not checking it adequately, and then people are making assumptions based on it which then translate into unrealistic expectations for clinical people.
You don't want to chart fraudulently. You don't want to risk losing needed reimbursement money. Can the staff get together and bring concerns to TPTB?
A simple fix would to have night shift start at 12, days at 8, and evenings at 4, then night shift 'would' unequivocally start the day, without the confusion. I've never seen that, though.
There is no 2nd shift in our facility. We work 12s.
Ah that makes more sense! But again, if you are charting after midnite on Feb 3 and you come in at 10:00 PM (or 2200) on Feb 3, the person has already been charted in that that 24 hour period. Obviosly a new admit would not fall under that scenario.
Exactly. I work 3-11:30 and as soon as the night nurses cone in, they chart the TARS (treatments performed) and Medicare documentation.
I have heard of nurses losing their licenses bec of this (doing the same thing and also including the MARs) because state came in, it wasn't time for the things they had charted, yet it was already documented. My mom has been a nurse for 30+ years and this happened at a nursing home where she worked, to the nurses on the night shift. When I oriented at my job, the nurse I worked with did the same thing, it's just the luck of the draw as to whether or not it will ever come back to bite you.
NutmeggeRN, BSN
2 Articles; 4,743 Posts
If the day starts at 0000 (12 midnight) any charting on that resident from midnite to the end of the shift counts as that day..... no?
So that would/should count as the SOMETHING
Cannot chart what you have not done
I do not see much discussion on the 2nd shift 2-10 PM or 3-11 PM and what charting they would be responsible for.