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.
What I've learned from mum is there is no such thing as 'charting to much'. If in court that is all you have then it needs to be as much information to cover your ass and make sure lawyers can't pick holes
What I've learned from mum is there is no such thing as 'charting to much'. If in court that is all you have then it needs to be as much information to cover your ass and make sure lawyers can't pick holes
There is definitely such a thing as "charting too much" if what you're charting comes off as too subjective or judgmental. I know nurses whose frustration and dislike of the pt comes out load and clear in their charting. A lawyer will have a field day with them. If they can convince a jury that you don't like a pt, they can easily convince them that you provided substandard care. And the more you ramble on and on in your charting, the more likely you will let something "too subjective" slip..... be objective and concise always.
As we have said, you can "chart too much". There is a balance that you need to find between too much and too little. The actual bedside care, including assisting your coworkers is also a priority. More importantly, if you are summoned to court, your charting will be scrutinized, so all the minor details which will be questioned could result in issues later. It goes both ways.
skittlebear
408 Posts
Another thing I was taught by a DON was to paint a picture while you chart. Maybe this is where I got it from. Hmmmm....