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 seem to write a lengthy note every 2 hours.
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.
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.
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.
I was taught that if it's not written down it didn't happen. Are they filling out the flowsheet and the narrative for everything? Maybe they are unaware that there is a place on the flowsheet for a lot of the info they are charting in notes..
Since these are new grads, they may not yet have recovered from doing those dadgum care plans. Honestly, pages and pages and pages of the most picayune minutiae on every teeny-tiny aspect of the patient's diagnoses, meds, v/s, treatments, devices, political persuasion, mother's blood type, and preferred pudding flavor. Flow charts probably seem like blasphemy.
it's 1:45 am here and I just finished a care plan (30+ pages of evidenced-based interventions and a full description of my patient's love for Bon Jovi)
dear RN/writer, can you please direct me to that 12-step group? I want to get help before I graduate and it's too late!
Maybe it's the way they were taught. During my ICU senior preceptorship, my preceptor had me include things like such and such infusing at xmL/hr in my narratives, even though it was on the flow sheet. Their nursing notes were very lengthy.
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 seem to write a lengthy note every 2 hours.
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.
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.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
The overly long drawn out hyper-detailed narratives make me crazy. It can be common in home health notes. There's a flow sheet to cover almost everything you might write in a narrative note, and if lawyers expected something to be written twice before it can actually be considered to have happened, there are a lot of missing narratives written by people who work in fast-paced high acuity units with lots of checklists for recording routine things and settings of equipment,etc.
I think if you put a brief summary geared to things pertinent to the patient's diagnosis and anything that has become worse, out of the ordinary and/or new, write that down and what you did/planned to do about that. An example from recently is a nurse's note narrative on a trach pt s/p dx of pneumonia and the note with everything under the sun except nowhere how many times the pt was suctioned, or what was being suctioned, and that's one the most important things I need to know.
I've noticed something new in the narrative lately by some people "patient kept dry and comfortable at all times - all needs met" To me, the only thing I can say for certain is that they were kept dry, unless they told me they were comfortable at all times, which is highly unlikely. As for "all needs met"; hmmm probably not.
As a new grad I am often unsure what to write out in my charting. In school we were taught that if we didn't chart it, it didn't happen. So don't write things like "vitals normal" write out the vitals. When you give IV meds you should assess the site, so document "site assessed for ...". I usually try to look at what others have charted, and learn from that.
I have never heard that charting too much puts you at risk legally. We were always taught complete charting will help protect you. For example if you charted "Pt tolerated procedure well", and two years later you are in court with said Pt who is saying "I was in agony, and kept begging the nurse to stop" you will have a leg to stand on. If you just charted on a flow sheet, it's just your word against theirs.
I do have a question though, and I am not being sarcastic or anything, I am just truly curious. What does it matter how much someone else writes? I don't care if someone else wants to chart a tome, as long as it isn't holding me up in my work. It seems from the responses in this thread that this is a real issue with people, and I am just curious why it matters.
I'm a new grad. I was always taught to include things not included elsewhere in the documentation, or things very important/out of the ordinary for the patient's stay when writing my note. Of course, since each facility includes different things in their documentation......it was always a little frustrating to switch clinical sites and figure out whether I had to include ADL's or ambulation in my note or not. For example, my unit has no spot to indicate that families were at the bedside assisting in patient care, so I always indicate it in my note.
Anyways. The whole 'cover you butt thing', yes, we were taught that. We were taught that charting it over and over again in several places (such as in the documentation, then in the note, etc) is not necessary, however. The only exception would be a major event. For example if I walked into a room and found a patient on the floor it would probably be noted in several places (incident form, note, etc).
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.
I'm a newer nurse (over 1 year but less than 2 years) experience and I'll be the first to admit, my notes are long.
However...I also work in Pediatrics...and we were taught that you should be able to look at the chart 18 years from now and be able to tell EXACTLY what you did that day.
When I was brand-spanking new, I used to get report that would take 20 minutes on one patient and then look at the chart (and this was from seasoned nurses) that would say, "Infant continues on q3 feedings via gavage/PO increasing as tolerated. Burped well and feeding retained."
To me, you will always get in trouble for writing too little, never for too much. Very gradually, I have scaled back my charting and I constantly look at what others write for new ways/shorter ways to chart things.
I personally, have never read notes that took me more than a couple of minutes to read and always value the information.
As a new grad I am often unsure what to write out in my charting. In school we were taught that if we didn't chart it, it didn't happen. So don't write things like "vitals normal" write out the vitals. When you give IV meds you should assess the site, so document "site assessed for ...". I usually try to look at what others have charted, and learn from that.
I have never heard that charting too much puts you at risk legally. We were always taught complete charting will help protect you. For example if you charted "Pt tolerated procedure well", and two years later you are in court with said Pt who is saying "I was in agony, and kept begging the nurse to stop" you will have a leg to stand on. If you just charted on a flow sheet, it's just your word against theirs.
I do have a question though, and I am not being sarcastic or anything, I am just truly curious. What does it matter how much someone else writes? I don't care if someone else wants to chart a tome, as long as it isn't holding me up in my work. It seems from the responses in this thread that this is a real issue with people, and I am just curious why it matters.
However, you can write "vitals normal" if they are charted somewhere else, such as a flow-sheet and if someone told you a flow sheet doesn't matter I can tell you now that is incorrect. Flow sheets are dated, timed, signed and part of the patient chart...I always reference the flow sheet when I do something like that...double charting is not necessary and if it's located somewhere else in the chart with my intials or signature? I reference it but I don't repeat it.
If you chart "patient tolerated well" means the patient had little to no reaction. In severe pain and patient complaining is not "tolerating well" by anyone's standard...therefore, I would stand behind it if I charted that.
I do have a question though, and I am not being sarcastic or anything, I am just truly curious. What does it matter how much someone else writes? I don't care if someone else wants to chart a tome, as long as it isn't holding me up in my work. It seems from the responses in this thread that this is a real issue with people, and I am just curious why it matters.
Personally, I was just curious what others do. I am comfortable with my charting by exception and see no reason to double chart anything. Just wondering, that's all. :)
One of the nurses on my floor was called into court regarding a patient and she told that she charts by exception (if nothing was wrong, it wasn't noted on the chart) b/c the more you write...the more the lawyer has to go on and the more questions he'll ask you. Less is more in nursing definitely.
aei631
27 Posts
I was taught that if it's not written down it didn't happen. Are they filling out the flowsheet and the narrative for everything? Maybe they are unaware that there is a place on the flowsheet for a lot of the info they are charting in notes..