I Chart Too Much?!

Altra, BSN, RN · Dec 17, 2012

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 · Dec 17, 2012

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 · Dec 17, 2012

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, MSN, RN, NP · Dec 17, 2012

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 · Dec 17, 2012

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 · Dec 17, 2012

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 :)

nurseprnRN, BSN, RN · Dec 17, 2012

I dunno. One of the nicest things a doc ever said to me was to compliment me on my charting. He said he could really see what the patient looked like and did from my writing, and it was so valuable to him. I review a lot of charts for med mal and other problems, and IMHO if you think of charting less as a CYA thang and more of a storytelling thang, you can't go wrong if you get the story right.

sapphire18 · Dec 18, 2012

I don't really think you can chart "too much"...but then I use a system that is mostly just checking boxes. :whistling:

Ntheboat2 · Dec 18, 2012

I think I've found a happy medium with charting because I was also under the impression from professors that EVERYTHING should be charted. Then, I got onto the floor and saw what others were doing and what was actually sufficient.

One example I can think of is when a patient requested a medication and the doctor was called. The doctor basically said, "No. I'm not giving him anything else because he doesn't need it." So, when I was charting, I wrote something like, "Patient reported nausea (?) and requested additional medication. Doctor Blank was notified, but did not order additional medication at this time, and stated that he will assess patient's condition in the morning."....or something like that.

My preceptor was like...umm...no. :roflmao:

I thought it sounded beautiful! She rewrote it to say, "Patient reported nausea and requested additional medication. Dr. Blank was notified. No new orders were received."

Yeah...that pretty much covers it without throwing someone under the bus should the charts be picked apart.

I think I'm pretty good at being concise now without leaving things out either. I know one nurse who literally writes like a page and that's typed. I think she's one of those that just does it to avoid having to do anything else though bc she rarely gets out of her chair. I asked one of the nurses how many years you had to work before you got to be the "chair nurse." :roflmao:

Like one of my professors said, "If you want to be the nurse who spends time with the patients then you'll find a way, but if you want to sit at the nurse's station then you can always find a way to do that too.":yes:

joanna73, BSN, RN · Dec 18, 2012

There is definitely a balance between charting too much and too little. For example, unless it is pertinent to their plan of care, I probably wouldn't chart, "Family visiting at bedside. No voiced complaints." However, if something important was said or observed while family was at the bedside, then I would chart that. If you chart every little thing, then you will get behind with the actual patient care.

wooh, BSN, RN · Dec 18, 2012

Problems come when you pay more attention to the charting than to the patient or when you double document. Multiple people are telling OP this, it would be prudent for OP to do some introspection and consider that maybe there's something to it. Maybe there's not, but it would be prudent to take it under consideration.

blondy2061h, MSN, RN · Dec 18, 2012

It's weird because everyone says how horrible double documenting is, but our system is set up with so much double documenting built in it's insane. For example, you chart a pain assessment with vital signs, with your nursing assessment, and again on the opiate drip flowsheet if they have a drip of some sort. That's just once example.