I have started a new job in a new hospital and of course there are differences in policies, but one that I'm particularly concerned about is free-text charting. In my previous job, we were instructed to keep free-text charting to a minimum as what you write can be taken the wrong way (in court). We generally would write notes, but they would be very vague and they were really intended to just chart that you did indeed do a rounding with the patient.
In my new job, the nurses do a free-text note that is intended to give the oncoming shift a rundown of what has been going on with the patient in general, and specifically during your shift. I agree that communication is extremely important, but I feel uncomfortable ENTERING this communication into the patient's permanent chart. It seems to me that free texting about medications I gave, descriptions of wounds etc. is double charting since I've already carefully documented my assessment in the chart. Also, there doesn't seem to be a standard for this, everyone does it very differently and it's not even mandatory. A few nurses say they refuse to enter these notes because of the legal implications.
Any thoughts on this? I'm a little confused and not sure what to think.
