Looooong narrative notes

canesdukegirl, BSN, RN · Sep 21, 2010

i have been nursing for a while now. i work with a few newer nurses in the icu. by "newer" i mean 1-2 years. they are great nurses, however, their narrative nurses notes are so long. we do paper charting. they chart tons of things- many of which are unnecessary (in my opinion) because we have flow sheets that address most of the information needed to be recorded. they seems to write a lengthy note every 2 hours.
where do they find the time?!?! i wish i had that much time!
mine are short and to the point: doctors rounding or doctors called, prn meds given, how many feet they ambulated, social issues, or other pertinant infomation that needs to be charted, etc... they only time my notes are lengthy is if there was an event (fall/code) or their status changes and/or they become unstable. i document on our flow sheets every 2hrs but not narratively every 2 hours. basically, if i was an uneventful day, i write an opening note, maybe something mid shift and a short closing note. i see no reason to write " d5ns infusing via pump @ 150ml/hr. site healthy, no redness, etc...." there is a spot to write the fluids/site check on the flow sheet.
agreed, maybe you should show them that their charting can be scaled back.
my question is what do they teach in school nowadays? we are geared towards charting by exception. i was taught that the more info you give the more evidence for lawyers to tear apart.
totally agree with this. the more you write, the more that lawyers can play with. maybe the nurse manager can do an education day in the art of charting. this is always helpful, and we can all gain some insight into brief, but complete and factual charting.
i like to work smart, not hard.
what do you do/think?

i agree with you. maybe they are just wanting to go above and beyond but not necessarily knowing that "less is more" in regards to narrative charting.

rn/writer, RN · Sep 21, 2010

Maybe they are still at the stage where they have to mention everything they do to make certain they don't miss any important stuff.

Could you take a page of charting (without any identifying info, of course) or make up one of your own and use a highlighter to show the unnecessary verbiage?

If you do this with an attitude of trying to take some of the time pressure off of them, they might be willing to consider shortening the novels.

Keep in mind, though, that streamlining is an art and has to be learned. I can't remember who, but a famous author once apologized for the length of a letter, saying he hadn't had the time to be brief.

General E. Speaking, RN, RN · Sep 21, 2010

They seem to get their work done. Maybe they took a course in speed writing!

I guess the point of my thread was to find out what others do or have witnessed. I am fairly new to the ICU and don't yet want to start giving unsolicited advice. I am a "seasoned" nurse but still learning the ropes in the unit.

miss_vtRN · Sep 21, 2010

As far as I've heard, charting by exception is a lawyer's worst nightmare...they prefer having proof that you actually did something, in WRITING, not just a check mark...so sounds like your new nurses are just trying to cover their butt, whether or not it creates more work in the end.

grandmawrinkle · Sep 21, 2010

I don't get the whole writing 3 notes a shift thing. We have a (computerized) flow sheet, then I typically will write a summary narrative note (usually short) at the end, plus any other mandatory charting (care plan, skin assessment template, restraints template, whatever.) Why 3 notes? Why don't you just wait until the end of the shift and do it all at once?

I've seen a few nurses do this, usually agency. It's not standard at my facility. What is the point of charting like that (obviously you do it?)

General E. Speaking, RN, RN · Sep 21, 2010

I realize the check marks on my flow sheet serve the purpose of me taking care of the patient. Habit, I guess for me. Beginning, middle, end!

himilayaneyes · Sep 21, 2010

I agree with you that less is definitely more. However, precise nursing notes are something that must be learned. I remember in clinicals, the instructors wanted so many details about absolutely everything. Perhaps those newer nurses are just continuing that practice. Take them under your wing. And yes, the more you write, the more a lawyer has to say to you in court. KISS! Keep It Short and Simple.

SlightlyMental_RN · Sep 21, 2010

All I can say is, thank you, God, for computer charting. I stink at narrative charting.

APRN., DNP, RN, APRN, NP · Sep 21, 2010

When I graduated from school over twenty years ago, I can remember an instructor telling me to "Paint a picture with words" when it came to my charting.

I have 100% computerized charting now in the ICU, with 100% computerized MD order entry. EKG's and such are scanned into the paperless medical record. I spend my entire shift "click" "click" "click" "click" "click" "click" "clicking"..... (did I mention that I click a LOT?). Clicking all the checkboxes. "ETT" Click #8 Shiley" Click...... Interspersed between the clicking, I can type in a "word picture" here and there as needed to cover my derriere.

I cannot even BEGIN to imagine writing a whole long-ol' narrative note every two hours.....let alone knowing where to BEGIN with all the mega info I would have to chart on a patient who is intubated and on 13 different drips and getting CRRT therapy! Sheesh. What a night mare.

On the positive side, it is not a bad thing to know what to chart. When the big picture starts to unfold, the narratives will become shorter.

blondy2061h, MSN, RN · Sep 21, 2010

I had the opposite problem when I was a new(er) nurse. I had a preceptor that told me I should be writing a note on everyone. I felt like my assessment flowsheets covered everything and only added a note when something else happened that wasn't covered in the flowsheet. If my patient had pain and I gave them dilaudid, after I filled out the pain assessment flowsheet and signed the dilaudid out on the MAR, I did not feel a need to write that the patient had pain and I gave them dilaudid.

I quickly realized that my preceptor wrote essentially the same note on everyone. That makes the note meaningless, in my opinion. I also found she jumped to conclusions in her notes, writing things like "assessment benign." I would never write that. I would write that their skin is intact, they have bowel sounds and a soft non-tender abdomen, that all of their pulses are present and regular, that their lungs are clear and their o2 sat is 98%, etc, etc, etc, but would never flat out say it's "benign."

My preceptor is a good nurse, but we had to agree to disagree on this topic.

On a typical night, between all of my patients, I might write one note. I've had nights where I've written 12 notes on each patient, but those are the unusual situations.

CorpsmanRN, BSN, RN · Sep 21, 2010

Having graduated this year, we didn't get much teaching in the way of narrative writing. It was just embedded in our brains to "document everything" in order to "cover your backside." But then we were also taught about charting by exception (which I found many felt like it wasn't enough & needed to include a little bit more info). Every time I had clinical I asked the nurse what they wrote & it was always sooo different. I'd also read the narratives of prior shifts to see how they wrote them out. One nurse's narrative included everything (even what was on the assessment chart/form) but in alphabet soup, nearly EVERYTHING was abbreviated. Some rarely ever wrote a note. I hate that we weren't taught even in general when to write narratives, what makes a good narrative note, what's too much or what's too little, etc.

If I were one of those new nurses you work with, I'd be ecstatic if you showed me how I could better my notes.