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I Chart Too Much?!

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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

Specializes in Oncology. Has 15 years experience.

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

Has 8+ years experience.

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

Specializes in MCH,NICU,NNsy,Educ,Village Nursing.

"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

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty. Has 5 years experience.

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

Specializes in Critical Care. Has 10 years experience.

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

Specializes in Hospital Education Coordinator.

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.

Edited by classicdame
spelling error

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

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...

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

Specializes in Oncology. Has 15 years experience.

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

Has 36 years experience.

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?

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.

Altra, BSN, RN

Specializes in Emergency & Trauma/Adult ICU.

Agree with the above: charting that can "doom" a nurse generally falls into the category of description of something concerning/abnormal without clear indication of what action/intervention was taken, and what was the patient's response to the intervention.

classicdame, MSN, EdD

Specializes in Hospital Education Coordinator.

excessive charting occurs when the nurse adds social or illrelevant information. Ex: "Wife, daughter and son-in-law at bedside arguing about how patient should be cared for at home. Asked for my advice and I said ....." Instead, the nurse could chart "family at bedside with questions about discharge. Referred to case manager."

blondy2061h, MSN, RN

Specializes in Oncology. Has 15 years experience.

Agree with the above: charting that can "doom" a nurse generally falls into the category of description of something concerning/abnormal without clear indication of what action/intervention was taken, and what was the patient's response to the intervention.

This falls into the category of charting too little in my opinion. It's important to chart changes in a patient's status, but if you haven't charted your intervention, then your charting is incomplete.

ThePrincessBride, BSN

Specializes in Med-Surg, NICU. Has 6 years experience.

I think you are doing the right thing. Nowadays, people are so law suit-happy. Ideally, a nurse/healthcare worker should chart EVERYTHING that they do on a patient, but you know how that goes....

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

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.

Duplicate charting got us into trouble more than once, there's too much opportunity for duplicate charting not to match in some miniscule way, but that's all it takes for a lawyer to find an opening.

Another was a situation that became both a civil and criminal case. A patient sued due to a fluid restriction order. It wasn't apparent at the time that he was upset about the fluid restriction, although he was suffering from some delirium. For whatever reason, a Nurse put "patient offered water, patient declined" in her note, which their lawyer then used to argue that the Nursing staff charts whenever they offer water, and since this was only charted once, it was argued (successfully) that during his entire stay the Nursing staff had only once offered the patient water.

It was true that we weren't giving patients sufficient opportunity to refuse a fluid restriction order, but some unnecessary charting which was thought to be harmless at the time ended up making some practice issues appear like intentional systematic abuse.

hodgieRN

Specializes in ER trauma, ICU - trauma, neuro surgical. Has 10 years experience.

A lawyers job is to win their case and they will do everything in their power to make you look incompetent. Now, if you are sitting on the stand with representation, the hospital-assigned lawyer can argue speculation or out-of scope, but during a deposition, you are on your own. Every word you write is a point of possible attack. Don't get me wrong....charting shouldn't be substandard or have anything left out that is pertinent to pt care, but I think if you write too much, it can be used to corner you. The lawyer doesn't care about your feelings, your job, your well-being, or how hard you worked to care for your pt. They dive right into your notes and go fishing. They hire other nurses to pick apart your notes and find inconsistencies. Even if it was a doctor that slipped up in surgery,they try find some way to pin excess blame on you so they can get more money from the hospital during a suit. They are looking for anything that might look like negligence. I chart that I spoke to the family and updated them on the pt's condition and plan of care and the family had no further questions. If you chart that and how the mother was upset or crying, they will come back and say you didn't recognize signs of distress, which mean you and the hospital are liable for emotional damages. BUT, that probably would stand up in court, but during your deposition when you are all alone in your seat with 3 other lawyers grilling you, it works as a great tactic to shake you and make you give up feelings or opinions that can move their case ahead. There's a reason why doctors don't write massive amounts of detail or opinions in their notes. They are taught to give the facts and plan of care or evals. When we use paper charting, I was taught to fill in my assessments and use the narrative notes for intervention/evaluation, unexpected events, or PRN tasks. I never double charted my assessment in the narrative. I did know a nurse that wrote her entire assessment in the narrative and was called to court and the lawyer grilled her. He argued that since she stated everything in the narrative, anything that wasn't in the narrative wasn't done, even if it was charted in the assessment. That doesn't hold up in court, but it suddenly did.... b/c she stated "Everything I do in my assessment, I write in the narrative." He was then able to use her statement against her since the narrative was the admitted go-to for her charting. Nothing ever came of it of course, because it's obviously very thin in the grand scheme of things. But he was trying to get her to admit that maybe everything isn't written in the narrative, which make her look like she was changing her position. It was tiny ploy that only lasted 10 seconds, but a lawyer uses different strategies and tactics to pick at you. Nurses are not educated on legal matters or self-representation, so nurses are the perfect target. " You said this...doesn't that mean something? Why not? How can you say that when you clearly you meant this. Isn't this what nurses are supposed to do?" It's an interrogation. I think you should write what you need to write. Give a clear, accurate description of your pt care including assessments, intervention, evaluations, task, and responses to matters concerning the family and pt. Every word after that will be scrutinized to label you as negligent, incompetent hospital worker. Just my opinion :)