How do you get the nursing care done with hourly rounding & computer documentation?

[medsurgrnco]

I work on a high-acuity med/surg unit and typically have 6 patients. We are now expected to do walking rounds, hourly rounding on patients documented on a form at the patient room (alternating with CNA's who often don't do it), document extensively in Meditech, do 24-hour chart checks, and respond promptly to patient phone calls and bed alarms. Anyone have any advice on how to get everything done timely? Also, does anyone have suggestions on how to document quickly in Meditech? I've used the system long enough to know the basic key functions and we can use the F5 key, but those F9 lookup tables are long and cumbersome. And doing patient orders is difficult as I often have to make many guesses to find an item.

[medsurgrnco, BSN, RN]

Anyone have advice on how to improve my organization of tasks?

This is my current strategy starting with 5 patients, after I get done with shift report / walking rounds, but typically pt needs take up more of my time so I have overtime in order to get all the computer documentation done.

2000 - 2300 Assessments & Meds (with repeated interruptions)

2300 - 0030 New admit

0030 - 0100 Lunch

0100 - 0600 Chart checks, Documentation (Meditech), Rounds,

Meds during this time period, Update charge RN

0600 - 0700 AM meds

Also, do others think it works better to do assessments & meds at the same time, or to focus on assessments first and then do meds? How much do you worry about meds being given on time?

[oldiebutgoodie, RN]

Anyone have advice on how to improve my organization of tasks?

This is my current strategy starting with 5 patients, after I get done with shift report / walking rounds, but typically pt needs take up more of my time so I have overtime in order to get all the computer documentation done.

2000 - 2300 Assessments & Meds (with repeated interruptions)

2300 - 0030 New admit

0030 - 0100 Lunch

0100 - 0600 Chart checks, Documentation (Meditech), Rounds,

Meds during this time period, Update charge RN

0600 - 0700 AM meds

Also, do others think it works better to do assessments & meds at the same time, or to focus on assessments first and then do meds? How much do you worry about meds being given on time?

I didn't worry about meds getting done exactly on time (unless they were really important and time dependent, which most meds are not--giving the Colace a half an hour late is not a big deal), under the assumption if the hospital is going to give me ungodly lots to do, they ain't gonna get perfection.

Frankly, I often did half n half-- I would try to give meds and assessments together with my really med-heavy patients, and split up the healthier/less medicated patients. It seemed to work for me.

Probably the other thing I could suggest is to carry as much stuff around as possible, and as you go in a room, if you have a dressing change due later, dump all the stuff in the room earlier so you are ready. Also, when I am doing my first rounds/assessments, I eyeball the IV fluids, and put another bag in the room so when the first one runs out, I'm ready.

Sorry-that's all I've got. That, and the magic wand/beans/incantations.

Oldiebutgoodie

[medsurgrnco, BSN, RN]

Thanks for the response. I do carry extra NS syringes, check for when IVF will run out so that I know when a bag is due, and look for dressing change supplies, check for IV tubing changes, missing fall risk bands, etc. when doing assessments so I know what I need to take in later. The main problem I seem to have is all the interruptions with patient needs & calls, leftover stuff from day shift, and early admits.

[bigredrn57]

So nobody in this forum has a clue how to satisfy all the current expectations of RNs in units like mine, even tho management thinks it can all be done? Obviously no RN can do all assessments & meds due in the first 3 hours of the shift on 5-6 high-acuity med/surg patients when part of that time is taken up getting report, giving report to the CNAs, answering pt/family questions, leftover stuff from day RNs, with repeated interruptions from phone calls and bed alarms and pts needing assist to BSC, and having to inefficiently do your tasks because you must go do your hourly rounds. How in the world could anyone also computer document during that time? And if you get an admit in that time period... I've read elsewhere that RNs typically spend 1-2 hours after their shift ends completing documentation, but management really hates paying for overtime, and it's hard to document accurately so much later and when I'm so wiped from running top speed all night and not having time to take breaks I'm entitled to in order to care of myself. So how do other RNs prioritize all the tasks? If I don't make patient care my priority and cut corners, then I compromise patient care/safety.... Yet if any adverse event occurs, not fulfilling the documentation expectations timely will be treated as proof that I'm not providing good patient care. And if CNAs are found lacking in their work, then it's my fault I didn't fix that problem. With Pyxis machines, tracer tags, and rounding sheets, management can easily check the timing of your tasks and get on your case if you don't meet time expectations. Anyway, I'll switch my account so anyone can send private messages, in case that'll increase responses as maybe others don't feel safe discussing this stuff in this forum. Again, I'd really appreciate any advice or comments from others!

Sounds like where I came from. I worked with Medi-crap for 3 years. There are no short cuts. Take care of your patients first, always. When management gets on your case sugggest they show you how to do everything while carrying a full team. A leader leads by example, a manager tells people what to do. Who would you rather work for? But be prepared for retaliation.

[Batman24]

I would ban together with the other nurses and let them if tasks are being added they need to add more nurses. That's the real answer as to what has to happen but they won't like that. Too bad. Do it anyway and follow up in writing so they can't ignore your concerns and you have a paper trail started.

You flat out can't get all that done. You need to provide good patient care first and foremost. You always make acute patients with medical needs your top priority before the blankets, water requests, etc. If your CNAs aren't doing their job then you need to start writing them up to make management aware. Hopefully other nurses will do the same.

There will be times you can round hourly and time you can't. New admits and fresh post-ops just won't allow for it. I would go to your manager at these times and let them know. Don't hide from it as you can't be it two places at the same time. They need to see this isn't doable and the more nurses that are willing to speak up the better.

[medsurgrnco, BSN, RN]

Thanks for the replies. I'm no longer at that job. Now I'm a psych nurse. No computer charting, no hourly rounding, no acute care patients, no call lights, no needy families. What a nice change!

[CO2emission]

We don't use Meditech, but my hospital just started doing the same things - mandatory hourly rounding and document on top of the SBAR type form for each patient in addition to the normal report sheet and we already did 24-hour chart checks. All this is well and good if we only had 3 patients, but as you said, with six it's nearly impossible. I try my best to round often and spend as much time as I can with my patients, but one new admit or fresh post-op and that chews up a solid hour right there. It' almost like they're looking for one more way to hang us! In addition, because they evidently don't have enough to do at the administrative level, they've decided that nurses aren't allowed to wear print scrub tops of any kind any more - all solids.

Hi,

This mightn't be much help but in Aus, reflective journaling carries a bit of weight. When you come to document in the patient's notes, you be honest, and write "unable to document progress due to workload and the provision of nursing care". Keep a little diary in your pocket; note the time and what you are doing; keep journaling throughout your shift in the form of a list with everything you do and if you don't have time at work, rather than staying back to do "paperwork" say "Sorry, Ive been too busy delivering patient care and unless I am paid for overtime see ya later". Than you go home and spend 15 minutes expanding on your diary by reflective journaling. You then go and put in an incident form or patient safety form or SBAR or whatever you use in the US and report it. Your journal will back you up when you get the please explain. If everyone does that for a week someone will eventually take notice and come up with a solution. If that doesn't work, you set up your patients to complain on your behalf. Management always listens to patients!

[UM Review RN, ASN, RN]

Hi,

This mightn't be much help but in Aus, reflective journaling carries a bit of weight. When you come to document in the patient's notes, you be honest, and write "unable to document progress due to workload and the provision of nursing care". Keep a little diary in your pocket; note the time and what you are doing; keep journaling throughout your shift in the form of a list with everything you do and if you don't have time at work, rather than staying back to do "paperwork" say "Sorry, Ive been too busy delivering patient care and unless I am paid for overtime see ya later". Than you go home and spend 15 minutes expanding on your diary by reflective journaling. You then go and put in an incident form or patient safety form or SBAR or whatever you use in the US and report it. Your journal will back you up when you get the please explain. If everyone does that for a week someone will eventually take notice and come up with a solution. If that doesn't work, you set up your patients to complain on your behalf. Management always listens to patients!

I wish something like that would work here where I am, but all that would happen is that the nurse would be fired for being too slow. We're also not allowed to say things that make the hospital look bad, especially in the chart, as that could open the hospital up to a lawsuit.

This is an at-will state, meaning anyone can be fired for any reason. We also have no unions here. So we're really between a rock and a hard place. We just do the best we can and hope that nobody's out to get us, because we all fall short.

[mscsrjhm]

Anyone have advice on how to improve my organization of tasks?

This is my current strategy starting with 5 patients, after I get done with shift report / walking rounds, but typically pt needs take up more of my time so I have overtime in order to get all the computer documentation done.

2000 - 2300 Assessments & Meds (with repeated interruptions)

2300 - 0030 New admit

0030 - 0100 Lunch

0100 - 0600 Chart checks, Documentation (Meditech), Rounds,

Meds during this time period, Update charge RN

0600 - 0700 AM meds

Obviously, your problem lies between 0030 to 0100. You probably take an occasional selfish bathroom break also. Tsk tsk tsk.

I like Meditech, and having all info at my fingertips, but have to agree with all- the tasks assigned amount to 16 hours of work- but we only have 12 hours to perform it. Nothing has changed for years- it just keeps getting worse.

[CO2emission]

I wish something like that would work here where I am, but all that would happen is that the nurse would be fired for being too slow. We're also not allowed to say things that make the hospital look bad, especially in the chart, as that could open the hospital up to a lawsuit.

This is an at-will state, meaning anyone can be fired for any reason. We also have no unions here. So we're really between a rock and a hard place. We just do the best we can and hope that nobody's out to get us, because we all fall short.

Goodness, that is so bad! The health care system (public) that most of us work for was very quick to recognise that when things go wrong it is because there is something wrong with the system. On an individual basis, we have a "no blame" ethos. If an individual does something wrong then questions are asked about how the system allowed that individual to do that wrong. Additionally, our employers accept vicarious liability for our actions that are covered by their own insurance. If our employers want to sack us, they have to go through a disciplinary process that takes about six months. Our union supports us to the hilt all the way. If a nurse breaks the law or the code of conduct, they are reported to the Registration Board and a formal enquiry takes place. The Board can then revoke a registration until a later date which is then reviewed for reinstatement. Until this happens a Registered Nurse cannot practice. I don't know of anyone personally that this has happened to. You poor guys...it sounds like employment conditions from the 1900's. How can you care for others when no one cares for you?

[Chaya, ASN, RN]

Rounding is one of those things that looks great on paper...In real life, ' tho, it would only be possible if TPTB who are demanding I do this could guarantee me no interruptions for the time it took to accomplish it. Maybe one of these administrator types could sit at the desk and divert all the calls/ interruptions that come my way during a typical say, 10 min period "rounding" would take:

calls from MD's to take telephone orders, calls from the lab to give results, calls from family members wanting an update: "Chaya is doing patient rounds; could I help you now or could she call you later"?

call lights where the patient wants his "nurse" and I get overhead paged and drop what I'm doing to go in and find it was for something any staff member could have provided. (I really don't mind getting lights/ providing care BUT it irks me to stop getting somebody's meds out of the Pyxis and go in there to find-what they wanted was to request their meds. Or be interrupted when I'm about to give someone pain meds or do a dressing and it turns out the person whose room I rush into is looking for a copy of the daily menu...)

There is a link in this current allnurses newsletter to an article which breaks down into time segments how (and I think it was Med/ Surg) nurses spend their day. What a surprise-doing paperwork was the largest single chunk of their time. Although if you combine giving meds and other patient care it was about the same. I mean-where do TPTB think the time for extra paperwork comes from? Ya get "spoken to" if you don't get to ALL of it, you get admonished if you stay extra todo it all-what do they think you're gonna do?

I come in at an "off" time so I will frequently pick up a patient from someone who expected to have them for the whole shift. Lately I've been noticing that even the most go-by-the-book RN's are filling in all every-other-hour time safety checks, etc ahead of time for the entire shift.

I'm just sayin'.

[SoundofMusic]

I don't think there is a way to get it ALL done. I am forever passing something on to the next shift -- most of all, patient care items -- dressing changes especially. I just can't get to that sort of thing on day shift with so much going on. Night shift usually has a bit more time to tie up the loose ends for me and on our unit, everyone is very understanding.

I am for hourly rounding as I do feel it gets you in there just to look if need be -- just to check. Lots of time it will tie me up, though, with silly requests that could have waited - and lots of times it helps me catch things with patients that needed to be caught in time.

I don't know why we have such a lengthy documentation process, though. i find myself double documenting in many places. And if they're NOT a code walker, I have no idea why I have to fill that form out everyday on every patient.

I've been told to maintain ABC's and priorities, but also that if I stay late and it's a habit, i'll get a talking to -- I mean, I think it's all a very ridiculous situation.

I also feel I have ZERO time to talk to that patient who might just need a few minutes of talking, chatting, or companionship to cheer them up. No time for that it seems, and that makes me sad. You can't get to know your patients -- I can't imagine how it makes THEM feel sometimes when their nurse just whizzes by and bolts out of the room as soon as we're done. We do that all day long ...