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!
