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.
Another pitfall of charting long notes is that if there is any discrepancy between the flowsheets and the narrative, no matter how small, that can be used against you. Anyone who wants to do the long notes, make sure that everything is consistent.
After that, if I did it, I document it in as much detail as possible. If I didn't do it, then I document why.
If anyone else has a problem with it, well sorry about that. If/when they have to go to Court they will see where I am coming from.
While an opinion can be compelling to some when stated as a point of fact, details anonymously transmitted over the internet, would be even more so in allowing others to come to their own conclusions.
My involvement in giving a deposition for a lawsuit consisted of the opposing lawyer going line for line over every one of my nurses notes and grilling me on them. I was just as perplexed afterwards about whether I had charted too much or had charted not enough or whether I stated the wrong thing. The best way to prepare for such an ordeal is to go through it. Then you see the need for careful charting afterwards. By charting what I had done I believe I was better able to deflect their attempts to saddle me with responsibility instead of the other nurse(s) involved. But I still think twice or three times about what I am charting, every shift that I work.
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.
For what purpose then, if flow sheets were not designed with the intent of streamlining data?
"Working smart, not hard", as you eloquently stated, leaves you free to notice the really important things.
I'm a new nurse and I chart more than the 'seasoned' nurses. Right now I'm just making sure I'm as thorough as possible. We were always told that it couldn't hurt to chart what we did. CYA is even what we were told during orientation. Plus, I'm always a bit nervous that I missed a spot to chart something. There seems to be so many places to chart the same thing that I automatically put it in my notes just in case. As I get more into the routine, I'm sure I'll ease up. I would rather overdo it rather than not do enough right now.
For what purpose then, if flow sheets were not designed with the intent of streamlining data?
I have no idea. Eventually, I will get up the nerve to mention it. Right now I am still learning the ropes and have no desire to start calling other nurses out on their idiosyncrasies or charting habits. I mean if you initial the flow sheet that says "call bell within reach" why is it necessary to write "call bell within reach"?
I was watching another nurses patients while she was at lunch and needed to check something on her clipboard while she was off the floor. That's the only reason I even noticed it. Her narrative page was was already 3/4 full and it was barely 11:30. Most of what she charted narratively could/should have been addressed in the nurses flow sheet section under the different body systems sections (lungs clear, bowels sounds, neuro status, etc...)
I knew there were others who probably do the same thing so I decided to post a thread to get some insight into the matter.
I have been through a deposition before and luckily the patient in question had been admitted at the end of my shift so there wasn't a lot to "grill me" on. It was still intimidating. Going through that nerve-wrecking experience does make you think about lawyers combing through your notes everytime you chart. However, I still think charting by exception is the way to go. If and when there is an event/fall/status change/code, of course, then it's all about the details.
Specializes in LTC, home health, critical care, pulmonary nursing.
New nurses tend to write books. I can flip back in a pts notes from 3 years ago when I was a new nurse, and I was WAY more wordy than I am now. A lot of our newer nurses chart some interesting things. My favorite, when a nurse was doing a shift note on a pt getting antibiotics, was "Blanket applied to conserve body heat." Wrong? No. Necessary? Lol. No.
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I mean if you initial the flow sheet that says "call bell within reach" why is it necessary to write "call bell within reach"?
rn/writer, RN
9 Articles; 4,168 Posts
Another pitfall of charting long notes is that if there is any discrepancy between the flowsheets and the narrative, no matter how small, that can be used against you. Anyone who wants to do the long notes, make sure that everything is consistent.