If it wasn't charted it didn't happen

nurseyNJNYC · Oct 14, 2010

always CYA.

hannor · Oct 14, 2010

thought only those necessary things we do to the patient will be recorded.. :confused:

tepbsmith · Oct 14, 2010

there isn't going to be any way to write additional notes? i find that hard to believe. i would suggest asking your nurse manager how that will be handled.

hannor- charting is not only for things we do for/to the pt. ex: you have a pt that is high risk for falls. as in, they are doing everything they can to get out of that bed and you can't restrain them (for whatever reason) you would need to chart every thing you did to prevent that pt from falling. sr up x2, bed alarm on, call light within reach etc. because if/when that pt falls that is what they are going to look at. also, there may be times when you need a doc to clarify a med order or something and the doc won't return your page, etc. if you are holding a med or some other ordered intervention because of an incomplete order then you would need to document that (nicely...no need to crucify the residents in your documentation).

i bring these up as examples because they are both things that happened to me as a new floor nurse and although i did all the appropriate things, i did not think to document them.

OttawaRPN · Oct 14, 2010

Minute by minute shift summaries?? Yikes, how is such a thing possible.

As long as there's an area for progress notes, I don't see what the problem is.

klone, MSN, RN · Oct 14, 2010

At one facility I worked at, we charted by exception, but there was a page for nurses' notes, where most nurses would write anything of significance (e.g. Pt dangled and ambulated with RN assist; tolerated well.) Some nurses wrote a huge long note twice a shift, other nurses only wrote what wasn't covered in the checkoff, which IMO is truly charting by exception.

RNperdiem, RN · Oct 14, 2010

On my computer charting there is a section for notes.

It is just a blank screen where you type in things like doctors being contacted, family issues, etc.

I have given up worrying about "if it wasn't charted, it didn't happen" unless my instinct tells me to.

If you have been in nursing long enough, your judgement will tell you when additional charting is necessary and you will feel more comfortable using charting by exception for 95% of patients you encounter

classicdame, MSN, EdD · Oct 14, 2010

I think most of us freak out over any kind of change in our routine, so that may be the basis for this anxiety. I truly believe the nurse will be able to add remarks.

HamsterRN, ADN, RN · Oct 15, 2010

there isn't going to be any way to write additional notes? i find that hard to believe. i would suggest asking your nurse manager how that will be handled.
hannor- charting is not only for things we do for/to the pt. ex: you have a pt that is high risk for falls. as in, they are doing everything they can to get out of that bed and you can't restrain them (for whatever reason) you would need to chart every thing you did to prevent that pt from falling. sr up x2, bed alarm on, call light within reach etc. because if/when that pt falls that is what they are going to look at. also, there may be times when you need a doc to clarify a med order or something and the doc won't return your page, etc. if you are holding a med or some other ordered intervention because of an incomplete order then you would need to document that (nicely...no need to crucify the residents in your documentation).
i bring these up as examples because they are both things that happened to me as a new floor nurse and although i did all the appropriate things, i did not think to document them.

Wouldn't every patient have the call light within reach? If so, why chart that was done for some patients but not others. What happens when a patient falls that you didn't see coming and chart specifically that the call light was within reach?

These are all standards of care for a patient who is a fall risk. Charting on standards of care one-by-one is a good example of what we are trying to do away with, particularly when it is inconsistent.

HamsterRN, ADN, RN · Oct 15, 2010

Being a floor nurse myself, I believe floor nurses should have the final say in how they chart since it's their practice and their license. My personal preference is to only chart what others need to know to care for the patient, so I'm trying to make sure I'm still advocating for a nurse's veto power on changes to charting even though I agree with the proposed changes to how we chart.

Some of this is coming about due to the new HITECH act and meaningful use requirements. If you're not familiar with this yet, you'll probably encounter this at your facilities in the next few years; If you don't currently use an electronic health record (EHR), medicare will start to withhold re-imbursements starting in 5 years. The same goes for implementing computerized physician order entry (CPOE). EHR's will also need to be certified which will place some restraints on their structure and may limit charting that doesn't support clinical decision making.

I would think that if nurses wanted, they could still chart a minute by minute diary, but they would need to follow the structured note first based on our current plan and then chart the "diary" elsewhere.

Would charting what groups of standards of care in place without charting each standard individually be sufficient for all nurses to feel comfortable with such a system? (ie "Fall risk standards of care in use" instead of listing each one and charting on them separately)

tepbsmith · Oct 15, 2010

at the place i was working at the time, most of the charting was done by checking off boxes. i don't remember whether or not the fall precautions were specifically listed.

what i do remember is when my 70ish pt faceplanted in the bathroom after i narrowly missed grabbing him, i charted like a crazy woman about neuro assessment, etc after the fall.

the following morning the nurse mgr said "well, its good that you charted an assessment after he fell. but its more important that you chart what you did to prevent him from falling because thats really what risk mgmt is concerned about."

so..

i don't recall specifically whether the boxes on the shift assessment had already been checked for the day. but since that particular incident, i always made a separate (even if it was redundant) note detailing the fall precautions, the pts actions, etc. --for pts that were very likely to get out of bed--

thankfully i never had another pt fall quite the way that guy did and in my present job, it isnt as big of a problem.

i would think that people are going to chart in the way that feels most comfortable to them and maybe if there are concerns about a new charting system, it might be a good time to do an inservice on documentation and that might be very helpful to the staff.

BabyLady, BSN, RN · Oct 15, 2010

At my facility, we are going to be changing our charting system to one that will be truly "by exception" and I foresee some friction from some staff. We currently use an EHR that is essentially "by exeption", but it allows a lot of leeway for nurses who want to chart more than needed, both in their note and their worklist. The unneeded charting in the worklist won't be possible, and we won't really be able to allow nurses to write the minute-by-minute shift summaries that some use currently (ie 1400: gave patient blanket 1410: Pt watching TV, etc.)
For those that are opposed to or feel uncomfortable with charting by exception, what specific issues/concerns could be addressed that would help you feel more comfortable and supportive of such a system?

Obviously, we have to chart things that happened, but there are tons of aspects of charting that is incredibly subjective.

To me, my RN license belongs to me, not the hospital, and I am going to chart what I feel like I need to in order to protect myself.

I can't tell you how many times I get a 30 minute report on one patient to find three lines of dialogue charted.