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.

[annonymouse]

HI LIBBY, HI MMC51264; Hi everyone who has taken the time to help me out here! I really appreciate this!

Thank you for this guidance. I type like the wind, so the time it takes to enter a detailed note is null. I mean, my co workers have heard me typing and have actually commented " how in the world can you do that so fast?".....( old school typing class)....

We do have computers within the rooms. I have, since this managements' request, been directly entering inside the pt rooms as MMC has mentioned. This is ideal and very efficient.

I guess it does become difficult at times to chart within the pt room as I am talking with the pt and developing rappor......mostly because I like the effect that eye contact and body language has on the trust a pt develops with me ( and in turn the whole hospital staff)....and when I am typing; it sort of takes away from that. But, you are right......it is absolutely possible to medicate, assess and chart within the first two hours of the shift on all five patients. Of course though......this is only on an ideal and rare day! Usually there is not a distinct ability to do this in such an ideally orderly way....as my pager is ringing off for the new admit, the discharge, the post-op, the transfer.......the commode emergency....the bed alarm down the hall....on and on........

Maybe I am enjoying the communication aspect too much with the patients after working so long in the trauma/critical care realms where I really missed out on that one-on-one human connection aspect.

But, after all of your helpful comments; I have come to a distinct conclusion. While I am forging relationships with the senior nurse recruiters in the city at the major hospitals ( plan B's)...........I will complete the charting within the pt rooms as I assess and also as I forge the trusting nurse-patient relationship. Is still think I need to apologize to the patient a bit though because....hey.....I wish I could just be sitting here with you connecting but it is necessary to chart as we develop our plan of care and clarify our goals for the day. Patients can and do understand this is the way of the world nowadays.

Maybe if I am just 'uber' perfect with the timing of my pain reassessments ( whether rational or not re: management's demands)......I can survive this thing and stay at this hospital which I really like! And if I still end up having to insert at a later time, and am fired for that..well....then there is my plan B.....evolving at this moment.

Thank you all though; I feel more clarity that these demands of management are actually quite unreasonable and can actually see that money is the root of the issue here. For some strange reason, I'm really not upset about this conclusion at all. I just really needed to know if all of nursing is being held to these ridiculously impossible standards of computer charting.....and now I think I know....NO....and that gives me SOME small measure of comfort.

[annonymouse]

Oh Yes, Juan DeLaCruz, thank you too, and yay for being NP!! :) Yes, in ICU, no one is late for charting hourly vital signs because it is pretty darn easy to verify the hourly VS which is automatically added into the epic system via the monitor.....that had always been very easy for me and everyone I worked with. I do kind of miss my monitors here in med-surg!

[annonymouse]

And yes, Libby, I think I do chart somewhat protectively within the progress notes. I will have to consider this. Sometimes I think it is really necessary! But perhaps it has become a habit over the years watching nurses get doinked badly for not covering their a##$s.

Wow.....times are a changing.....and fast they are!!!!! Thanks you guys! I think I found all my answers! Nurses are some of my most favorite types of people in this world!!! : )

[BittyBabyGrower, MSN, RN]

We chart at the bedside. And if I have to have my back to a family I just tell them, I'm listening, I just have to enter this stuff.

I have over 30 years experience and I have to say I love EHR.

[DeeAngel]

Yes charting has become more important than patients because it provides the institution with plausible deniability and revenue enhancement. Administration will deny it to the ends of the earth, but yes it is more important to them than people. It's all about the APPEARANCE of having delivered good care, not whether or not you actually did. This is a predictable outcome when you put bean counters in charge of patient care who have never cared for a single patient.

[Libby1987]

I've learned in my position, behind the curtain, that meeting Medicare quality and reimbursement criteria is no simple matter and as much as patient care matters to me there's a balance of keeping the place viable in order to provide that care.

Perhaps it's different for the corporate giants where the revenue might be free flowing but out here in rural healthcare, the budgets are tight and it isn't a cash cow.

[TheCommuter, BSN, RN]

Yes, patient care definitely comes before charting...

However, I am going to be blunt. Management doesn't give a rat's behind whether you comforted Ms. Smith while hanging her infusions. They want the charting and timing done in strict accordance with policies and procedures. To them, patient care is secondary to adherence to facility policy.

[BSN16]

We chart at the bedside. And if I have to have my back to a family I just tell them, I'm listening, I just have to enter this stuff.

I have over 30 years experience and I have to say I love EHR.

I've been trying more to chart at bedside. Mainly because if im caught charting at the desk, people assume i'm not busy at all and usually end up doing other tasks and making me even more behind :/

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

Yes, patient care definitely comes before charting...

However, I am going to be blunt. Management doesn't give a rat's behind whether you comforted Ms. Smith while hanging her infusions. They want the charting and timing done in strict accordance with policies and procedures. To them, patient care is secondary to adherence to facility policy.

^^^^^^!!!!!! And it shows in the decreasing patient satisfaction scores; yet they wonder what happened.

[HouTx, BSN, MSN, EdD]

My risk management colleagues have told me that they are seeing an increasing amount of literature on the problems directly attributable to EHRs - such as 'copy and paste' ... without verifying the original information & checkbox syndrome - (if I can't just click it, it doesn't get entered). There is also evidence that EHRs are obstacles to physician critical thinking - they're getting used to checking boxes and having things pop up to help them..... no pop up, no problem, right? This is causing enormous problems when it comes to defending organizations from malpractice claims.

[mmc51264, BSN, MSN, RN]

I do not copy and paste EVER. I am lucky that our computers are situated that I can position my self to semi face my patients and the computer.

I love that I can chart in the room. Pt feel like you are spending more time with them, charting and pt care don't have to mutually exclusive.

Sometimes there are pts that are more sociable and the ones that want to talk, or sometimes need a sitter and there is none, I may spend extra time in a room to chart on other pts. just to keep an eye on someone that may have some mental status changes or are impulsive.

There can be advantages to the EHR :)

[NOADLS]

It is common knowledge that charting is a lot more important than the actual patient care that occurs.