Is charting coming before patient care these days?

[annonymouse]

Hi. I just tried to submit an informative question but somehow it was lost in transit. So briefly; I attempt again.........how many of you older nurses who have vast experience and are at the top of the pay scale, have been disciplined for your charting techniques?

It is being enforced to me by new management (in CA., a new state for me), that I should " minimize my progress notes"; and that "inserting assessments after the actual time of assessment" is going to get me fired.

I was trained that actual patient care and safety,(hands-on) comes before charting. If one has to insert at a later time the actual assessment (but with of course inserting the actual time the assessment was done).....does this legally make the nurse liable of neglect?

For instance, if a patient is falling and I were to miss my entry of sepsis screen because of rescuing a patient from injury......I would still be written up. EVEN if I were to insert the time of the actual assessment later......the auditor would see that the entry was later...and assume that I was neglecting this nursing duty.

In fact, I have been a nurse for so long, like many of you....that I can sense sepsis even before SEEING the patient. We reassess pain constantly, and respond swiftly. But if assessment is not entered into EPIC in REAL TIME......not inserted later as the time it was actually assessed.....we may get fired???????

I have 15 years experience within Level 1 trauma, flight nursing, and ED.....and now in Med-Surg; happily enjoying the conscience patients and the customer service/education element. I was hoping for a nice, calm entry into retirement in three years...at the top of the pay scale. I am now being written up for not entering charting at the exact time it happens.

As well, after saving two hospitals from terrible lawsuits because of my narrative and uber descriptive type of charting, I am being told to MINIMIZE MY PROGRESS NOTES....I am having a difficult time understanding these things. My progress notes have been complimented on for YEARS by nurses and physicians alike who appreciate the informative narratives which allow consistency of care!

Help me understand this insanity. Thank you.

[NurseGirl525, ASN, RN]

So, if you don't get to chart your 0800 assessment until say 1100, you can't change the charting time to 0800? You should chart everything as the time you did it.

Sometimes, I real time chart, but our stuff needs to be done on the hour so I chart my stuff on the hour.

I would think they just want you to chart things like your 0800 assessment as 0800. That's when you did it. I write everything down that I did and what time in my little book and chart it as the time I performed it.

Maybe they feel your detailed notes are too detailed or taking you too much time to complete? I'm not sure as I am not there.

[annonymouse]

Hi Nursegirl 525; thanks! The basic head to toe assessments may be inserted at actual time of performance, IE: assessed at 1530, didn't get to actually chart till 1900, but may still time the assessment at 1530. But the pain assessments and sepsis screen; must be entered exactly at the time due. For the sepsis screen this may be any time within the first two hours of shift. The pain assessments must be entered ON THE EXACT hour, in REAL TIME. So I gave Mr. Smith his PO pain dose at 1600,the reassessment must be entered at 1700; never inserted at 2200 with the time of 1700.

As for time management, I don't have a habit of clocking out late either.

I am asking if this is common practice; habits which most RNs in med-surg are being held accountable to. From what it sounds like from you; as with my 'informal' surveys amongst my co-workers; insertion of these items at a later time but clocked in the chart at actual time of assessment is common. Which makes sense. How can one actually be doing hands-on care when needed on a very briskly paced unit while stopping to chart, log in-log out....while a patient is needing something right now...." Sorry Mrs Jones, you'll just have to pee your pants because I have to put this assessment in the computer right now instead of help you to the commode"......Of course I'd never say that, but hoping you catch my drift.

Thanks for responding. Maybe I am being unreasonable. I just always learned the real patient comes before the chart.

[RNperdiem, RN]

Computerized charting has its downsides. You have discovered one of them. Nurses are more measured and audited than ever. Tie these in with legal and financial consequences, and you realize that charting is more than a communication record of patient care.

[HeySis, BSN, RN]

I agree, the patient first and chart later, I jot down things that I'm not likely to remember in real time and then go back in and fill in the spaces later. Our charting system allows for this (it looks like a spread sheet, So I quickly complete certain boxes and wait until I have a chance to go back for the rest)

Charting by exception is new to me too, and I really dislike it. But that is the way it's done now.... I'd rather chart

"abd soft, non-tender, non-distened, bowel sounds active x4 quads, pt denies pain upon palpation, no N/V/D."

Then the new way of marking a check box that whole assessment WNL and only going into detail if something was wrong. I would think legally the first is better coverage and proves I really listened, touched, assessed, and spoke with the patient. But I bow to the new rules.

I would ask for an example of a person that does all their charting the way they want it done and ask to shadow that person for a day to see what they do differently and if it's something you could incorporate into your own practice.

If that person ignores the patient in order to complete charting I'd look for somewhere else to work. If management is not able to site a person to learn from, then I'd worry they were on a witch hunt for some reason.... Maybe because you are a higher earner??? (I know some places still do that).

[annonymouse]

Thanks HeySis!, yes, I am in touch with senior nurse recruiters at this time looking for other options at local hospitals which I would like to check out. It's too bad because I am loving the current pt. population, and have forged nice relations with my co-workers....but hey that's nursing. Never had to deal with this type of stuff before in more acute settings! Yes, lots of hospitals would love to eliminate the higher earners when they can hire a fresh new grad and pay at least 20.00 less an hour.

Good idea, this shadowing opportunity. Let's see how this new manager takes that request.

Yes, there have been several RNs 'let go' recently for seemingly ridiculous reasons. I guess new managers get points for minimizing budgets.

Certainly complying to what I have been told. But of course, tomorrow it may be that my shoelaces are too dirty for managements' taste; there could always be a write-up for that too! heheee.

[Ruby Vee, BSN]

Epic is coming, Epic is coming and the sky may fall. We don't have it yet, but our sister units who DO have it have complained bitterly about it.

I suspect the key to your problems lies in your statement that you are a very experienced nurse at the top of your pay scale. I wouldn't claim ageism, exactly, because they can pay a 60 year old new grad about half of what they pay you. (Or less.) The problem isn't really your charting; it's just the thing they can use to get you. Try very hard to get the charting in by the required times, but patient care does come first. Best wishes.

[Corey Narry, MSN, RN, NP]

I don't work at the bedside as an RN but as an NP, I've not heard of RN's not being able to chart their notes later but still using the original time when they did the assessment. We also have Epic and I'm also in California albeit in a system that in unionized. I do know that nurses can get in trouble for not giving meds within allowed time frames which Epic can easily keep a close eye on with the requirement for bar code scanning. I also know that pain reassessments are also monitored. In the ICU, I've not seen any nurse be late with their hourly flowsheet vital signs.

[Here.I.Stand, BSN, RN]

I'm neither "older" nor at the top of the pay scale (I'm 37 and working 13 yrs, if you're on a phone and don't see my bio on the post.) But I agree with you completely! Patient care comes before charting every. Single. Time. We have Epic where I work, and charting in real time is ideal; however it is usually impossible. Sometimes I don't even get my q 2 hr restraint documentation--along with assessments and notes--in until after I report off. I won't skip my break to get it done on time either. Nobody has ever threatened me or any other RN on my unit about it. It goes without saying that the patient comes first. I mean, entering the sepsis screen is pretty small potatoes compared to doing oral care/subglottic suctioning and doing peri/Foley care and giving scheduled antibiotics.

[NurseGirl525, ASN, RN]

Hi Nursegirl 525; thanks! The basic head to toe assessments may be inserted at actual time of performance, IE: assessed at 1530, didn't get to actually chart till 1900, but may still time the assessment at 1530. But the pain assessments and sepsis screen; must be entered exactly at the time due. For the sepsis screen this may be any time within the first two hours of shift. The pain assessments must be entered ON THE EXACT hour, in REAL TIME. So I gave Mr. Smith his PO pain dose at 1600,the reassessment must be entered at 1700; never inserted at 2200 with the time of 1700.

As for time management, I don't have a habit of clocking out late either.

I am asking if this is common practice; habits which most RNs in med-surg are being held accountable to. From what it sounds like from you; as with my 'informal' surveys amongst my co-workers; insertion of these items at a later time but clocked in the chart at actual time of assessment is common. Which makes sense. How can one actually be doing hands-on care when needed on a very briskly paced unit while stopping to chart, log in-log out....while a patient is needing something right now...." Sorry Mrs Jones, you'll just have to pee your pants because I have to put this assessment in the computer right now instead of help you to the commode"......Of course I'd never say that, but hoping you catch my drift.

Thanks for responding. Maybe I am being unreasonable. I just always learned the real patient comes before the chart.

I have to also chart my pain reassessments within I think 60-90 minutes. I definitely go in and assess within 60 minutes, but I truly may not chart that until 3 hours later. Because, that patient may have had a bowel movement, or they need food ordered. Maybe more meds are due, tons usually happens!! To all of us. I just make sure that the reassessment for my 1600 assessment for pain if I gave a med is documented at 1700. I change the time.

I don't think you are making too much if it. I think you are offended by them telling you that your notes are too detailed. I don't think detailed communication notes are wrong. Unless it is taking you forever to input them. Often times, those little details are very helpful. Especially to us newbies!! But, not everybody appreciates them.

I would just get very clear direction on real time charting. I think that is very unreasonable. Just get clear direction that it's ok to chart it 3 hours later as low mg as you did the assessment. Sometimes, I have hourly neuros. I may not get them charted until 1600, but I do complete them on the hour. Thus, my handy notebook!!! I'm a dork, I know.

3 years from retirement? You go girl!! That is awesome!!!

[mmc51264, BSN, MSN, RN]

do you have computers in the rooms? I chart in the room while I am assessing. I can medicate and assess 5 pts in about 2 hours which is within our policy's time frame.

Where we ran into problems is that some nurses (neither old or new) prefer to write things down and then chart. Defeats the purpose. Obviously if an emergency arises and they are not going to be forgiving about that, then I would question it.

[Libby1987]

I think before I made a big change when there are only 3 years left at the top of the pay scale, that I would consider that they are asking you to reduce "uber descriptive" progress notes. Do you believe that very detailed defensive charting is protecting you and that's why you don't want to modify?

Could the time saved by reducing your narratives give you more time to chart in real time? ot must take some time to write that detail and then more time to type it in, could you use that time to log on and enter instead?