I Chart Too Much?!

[skittlebear]

My coworkers are always joking with me that I chart too much. It doesn't take up more time, I just chart everything I do. I have several jobs and at one job, for instance, I have two high acuity patients. Every time I do something with my patient I chart it. It is paper charting and I write very small. I can easily have a page and a half for each patient. A few of my coworkers may wait until the end of their shift to chart on everything. Some do as I do. After I preform a procedure, I chart.

Co-workers also joke with me at my other job. It's computer charting and I chart a summary after each patient. They will jokingly say, "I want that book signed when your finished."

Okay, here is my concern. Whilst in nursing school my instructor told me not to chart so much, that I could legally get in trouble should anything happen. I also know from common sense that "if it isn't charted it isn't done". I just chart the facts, nothing else. I chart what state the patient was in before I preform a procedure, what procedure I did...per orders, and what the outcome of the procedure was. I chart every hour on a patient sometimes when it is only required to chart every 2 hours but I just chart every time something is done....etc.

[blondy2061h, MSN, RN]

We recently implemented a new acuity rating system that pulls from our charting. I try and chart everything I do just so I can get higher acuity points. Every time I ask about pain or nausea, any oral care I do, each BM the patient has, anytime the patient is anxious, etc, etc, etc. We get acuity points for all of that and the more acute I can make my patients look, the better staffing we get. I don't lie, of course, I just take credit for what I do.

[SaoirseRN]

I would rather chart too much than not enough. I tend to chart more than some, including general updates throughout a day. For instance, "1530: patient visiting with family. Patient voiced no concerns at present. Denies pain/discomfort."

Shows I've checked on them and addressed potential needs.

[kakamegamama]

"If it isn't charted, it wasn't done" is sage advice. I review charts for malpractice cases. One of my hardest things is reading a chart, and seeing that important things were not charted. I cannot assume that those things were done. Therefore, there is no validation that it was done. And, the word of the nurse involved that he/she did do it, doesn't really matter without the proof. So yes, practice defensive nursing and chart, no shortcut.

[brillohead, ADN, RN]

My instructors have always told me that it could be 2-3 years later when you're giving a deposition on the care you gave a patient. You're probably not even going to remember anything about the patient, the only thing you'll have to go by is your charting. If you have the time to do the charting you're doing, go for it! if it's a situation where you and a coworker both have to testify about what happened, you're the only one with the documentation to back up the care you provided.

[MunoRN, RN]

I've been involved in many reviews of cases where lawsuits or BON discipline was involved, only one was due to insufficient charting, in many of the lawsuits with decisions not in our favor, it was excessive charting that doomed us.

Always chart to you standard, but also remember that lawyers can argue you chart to a different standard if chart unnecessarily which means you now have be consistent in maintaing that "other" standard you've established, if you're then inconsistent with that, then you're toast. Consistency is key, not total bulk of charting.

In general, chart in a manner that best benefits your patient. Chart what others caring for the patient need to know, and don't bury that useful information amongst a bunch of junk information. Chart for your patient, not for you. If you're charting with ypur patient's best interests in mind, you'll be fine.

[classicdame, MSN, EdD]

If more than one person is telling you the same thing, then you need to look at it more carefully. If you are putting in extraneous information then that might come back and bite you some day. Just chart the facts. Also, could it be you are charting to keep from actually doing something else? I worked with a nurse who wrote a tome on each patient, but was too busy charting to really get her work done or help the rest of us with other tasks. She "hid out" on the computer.

[KelRN215, BSN, RN]

I agree with MunoRN that consistency is the most important thing. I charted a lot when I worked inpatient but not excessively. Some people I worked with would administer meds and sign them off and then write a comment "meds given" on the flow sheet. All of our charting was on the computer so it was visible on the MAR that meds were signed off/given at 8:02. If you comment "meds given" at 8:05 but no meds were given at that time, does that leave someone wondering what you gave and didn't chart? Comments like that as well as ones that said "VS, assessment" or the like were a bit excessive. Someone reviewing your charting knows the VS were done if they are documented. Ditto with the assessment. When there were these comments but no VS or assessment charted, that drove me up the wall! Telling me you did it but not telling me you found is useless.

A former co-worker did once recall a case that went to court where the nurse's documentation was called into question... something happened where she gave a med (maybe morphine) and on the MAR signed it off as 1mg but then in her note, wrote "2 mg morphine given." It was several months-years later when it got brought up and at that point, she had no idea which one was correct. Not a good position to be in...

[netglow, ASN, RN]

Seems like many on this thread aren't fully on EMR yet? All things you're saying you chart are in the EMR menus - even family stuff - all can be clicked for the most part as part of an hourly rounding... I'd think you'd jot down notes a bit to pass on to oncoming nurse, but that's not EMR stuff.

[blondy2061h, MSN, RN]

I've been involved in many reviews of cases where lawsuits or BON discipline was involved, only one was due to insufficient charting, in many of the lawsuits with decisions not in our favor, it was excessive charting that doomed us.

Always chart to you standard, but also remember that lawyers can argue you chart to a different standard if chart unnecessarily which means you now have be consistent in maintaing that "other" standard you've established, if you're then inconsistent with that, then you're toast. Consistency is key, not total bulk of charting.

In general, chart in a manner that best benefits your patient. Chart what others caring for the patient need to know, and don't bury that useful information amongst a bunch of junk information. Chart for your patient, not for you. If you're charting with ypur patient's best interests in mind, you'll be fine.

Can you give an example where excessive charting would "doom" someone? I just found this post a bit confusing as to what you're referring to.

[brownbook]

I am awed that you can "chart to much......it doesn't take up more time.."

Yikes, I wish I could shadow you for a few shifts. I think your way is better than mine.

I don't really like charting, but know I am supposed to keep up, keep current. Yet most days I end up near the end of my shift illegibly scribbling hastily done lousy charting because I can't seem to keep up and keep current.

In my defense, which won't hold water in a court room, because I hate to chart I probably spend more time (to much time) with the patient, at their bedside, even making sure family and visitors are "cared for".

Honestly how in the heck do you do it?

[08RNGrad]

Nurses get into trouble when they chart without interventions. IE. patient short of breath. You better darn well show what you did in the situation. Say upon going into patient's room, patient disoriented, make sure you chart what you did. Say the patient has a full-blown stroke later, hopefully your charting would reflect you did a neuro exam and reported any abnormalities.