How do you avoid double/triple charting? Tips.

Florence NightinFAIL, BSN, RN · Jul 1, 2011

Hello,

I'm a new grad and charting is the bane of my existance. Many times I stay past my shift to complete charting. It's often times double/triple documenation. The flowsheets are supposed to make life easier but the unit 'culture' here is to chart whatever you ticked in the flowsheets which can really eat out the little time I have in my busy acute surgical unit.

I was fed up and made a little change to make life a bit easier. Instead of re-writing ALL the info contained in the flowsheets - I would document in the chart:

Assessment completed, please refer to the flowsheets for details.

That would cover the Loc & systems assessments. But I would also write a line or two about any lines, tubes, drsgs, prn meds and changes in the baseline.

It's still a lot to write but it does save me a few minutes here and there.

I also find it hard to coordinate all the times written in all those sheets - vital signs, chart, flowsheets, MAR etc. It gets confusing.

What do you do to keep your sanity and please share any tips you can spare!

I am wondering whether it would hurt me legally if I stopped double charting & refer to the flowsheets when the co-workers basically copy down the info on the flowsheets and often write half a page to a full page of documenation? I checked the policy and it does say chart by exception but I'm wondering whether its implied to follow whatever the unit culture of documenation is.

Argh! This is giving me a headache.

caliotter3 · Jul 1, 2011

How did my post get timed and posted before the OP?

Florence NightinFAIL, BSN, RN · Jul 1, 2011

As a new grad, I guess I'm not worthy enough to be on top. :crying2:

Art_Vandelay · Jul 1, 2011

How did my post get timed and posted before the OP?

hahahaha :lol2:

Florence NightinFAIL, BSN, RN · Jul 1, 2011

^I wrote after I saw your post and I'm put before you. LOL. Something is amiss here.-

caliotter3 · Jul 1, 2011

This also happened to something I posted yesterday. Somewhat aggravating. Hope they fix it. I don't think you are being picked on as a new grad. At least I hope not. :confused:

JulieCVICURN, BSN, RN · Jul 1, 2011

If your policy is chart by exception, do not do otherwise to satisfy "unit culture". We have this happen a lot and it's because people see all these options to chart in the computer and get caught up in thinking they have to respond wherever you can check or click or type something. You should not.

If you have areas where the same thing (like Head of Bed) is in multiple spots, only chart it in one or you run the risk of contradicting your own charting.

If you are using paper flowsheets, in my opinion it is fine to put in the electronic chart "See manual flowsheet" in theory, but it makes it difficult to see a complete record if someone goes back later. If that flowsheet is scanned into the record, then it shouldn't be a big deal. At our facility, those are scanned into the permanent electronic record.

Even I (who loves charting by exception) sometimes get caught up in charting too much. Don't do it! :)

psu_213, BSN, RN · Jul 1, 2011

This comes from the days (just about 2 yrs ago) when we had paper charting...

The charting "form" went system by system. It said what the normal was for a given system. For example, for neuro it was something to the effect of "A&Ox3, speaks clearly in full, legible sentences. Moves all extremeties. Follows commands. Face symmetrical. Equal strength in limbs bilaterally...etc, etc." (and, no, it did not actually say etc. etc., but you get the idea ). If the person met those standards, you would check "WNL." If something was not met, you would check what was abnormal. For example, if they were not oriented to time, you would check orientet to person and to place, not checking to time. Fairly simple and chart by exception. One nurse would go through the entire assessment and then write a novel for a note: "Pt A&Ox3, face symmetrical...bowel sounds +x4 quadrants, denies changes to bowel habits...able to ambulate without assistance, no difficulty noted, steady gait...etc." She repeated all of her "WNL" data. Just seemed like an incredible waste of time and definitely not charting by exception.

Its inevitible that somethings will be charted twice, but I aggree with someone who posted before that, for example, you should say "see flowsheet" rather than recharting all their vitals (plus, legally, it's not a good idea to rewrite the VS elsewhere in addition the the flowsheet, but that is a different discussion).

chicookie, BSN, RN · Jul 1, 2011

This also happened to something I posted yesterday. Somewhat aggravating. Hope they fix it. I don't think you are being picked on as a new grad. At least I hope not.

Now we know who the favorites are.... :lol2: :lol2: :lol2: :lol2:

bilsterz77 · Jul 2, 2011

This comes from the days (just about 2 yrs ago) when we had paper charting...
The charting "form" went system by system. It said what the normal was for a given system. For example, for neuro it was something to the effect of "A&Ox3, speaks clearly in full, legible sentences. Moves all extremeties. Follows commands. Face symmetrical. Equal strength in limbs bilaterally...etc, etc." (and, no, it did not actually say etc. etc., but you get the idea ). If the person met those standards, you would check "WNL." If something was not met, you would check what was abnormal. For example, if they were not oriented to time, you would check orientet to person and to place, not checking to time. Fairly simple and chart by exception. One nurse would go through the entire assessment and then write a novel for a note: "Pt A&Ox3, face symmetrical...bowel sounds +x4 quadrants, denies changes to bowel habits...able to ambulate without assistance, no difficulty noted, steady gait...etc." She repeated all of her "WNL" data. Just seemed like an incredible waste of time and definitely not charting by exception.
Its inevitible that somethings will be charted twice, but I aggree with someone who posted before that, for example, you should say "see flowsheet" rather than recharting all their vitals (plus, legally, it's not a good idea to rewrite the VS elsewhere in addition the the flowsheet, but that is a different discussion).

Why is it,legally, not a good idea to repeat the VS?

carolmaccas66, BSN, RN · Jul 2, 2011

I refuse to double chart. You can actually write in a column of the ob's chart 'refer to ....... chart for (whatever)'. I don't double/triple chart on computers either - I don't care what the policy is. It is such a g/damn waste of time. If nurses keep doing it, employers will keep demanding it. Tell your NUMs that you won't be doing it, point out how time wasting it all is.

And, from my viewpoint, if someone can't flick through a patient's details and pick everything relevant out in one go, then they should not be nursing.