Looooong narrative notes

[General E. Speaking, RN]

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.

I like to work smart, not hard.

What do you do/think?

[Flying ICU RN]

I do too, but think that's a majority of what the flowsheets are for!!

I love those flow sheets, that 30 minute marathon dressing, linen and tubing change session, is reduced to three check marks.

[General E. Speaking, RN, RN]

I love those flow sheets, that 30 minute marathon dressing, linen and tubing change session, is reduced to three check marks.

Right? Sorta makes you feel cheated cause in three check marks ALL your sweat and effort and great nursing care that took so long is documented! lol

[HollyHobby]

I have worked with some nurses who chart so excessively that they are unable to actually provide patient care. They depend on their neighbors to do almost all of the patient care, including giving their meds, toileting, dressing changes, baths, etc. etc. They sit there, hour after hour, charting frantically and complaining that they need more help.

So I end up answering their call lights, giving their meds, and basically doing everything else while they chart and chart and chart. Plus I have my own patients to care for and my own charting to do, of course. If I suggest she'd have more time with her patients if she cut back on the double, triple, and quadruple charting, she looks at me like I am the most despicable person on earth. No WAY is she going to compromise her "standards".

These are the kinds of nurses who chart in the narrative notes things like this (I am not exaggerating): "Vancomycin one gram given IV piggyback via pump with normal saline rider to IV in L AC. See MAR for details of medication administration. See Assessment documentation for IV site assessment. Pt tolerated antibiotic well with no s/s of adverse reaction. Vital signs stable before and after infusion. Vancomycin piggyback infused over one hour (250ml), then normal saline resumed at 100ml/hr per doctor's orders. Will continue to monitor."

When this kind of person has to titrate a drip, the charting can become so fabulous that she will have to stay hours after her shift writing about it all. Even though she's already noted it on the flowsheet, which is all that needs to be said, and which takes only a few seconds.

NONE of that had to be written. And if she hadn't been writing the world's most boring novel, she would have had time to actually hang the vanc herself, instead of asking me to do it.

[Flying ICU RN]

They depend on their neighbors to do almost all of the patient care, including giving their meds, toileting, dressing changes, baths, etc. etc.

Someone who does not have the time to give meds and or change dressings, also does not have time to be a nurse.

Short of rescue, toileting, and pushing a tray within reach, you are under no obligation legally or morally to lift a finger otherwise.

[smartnurse1982]

In some states,if there was a lawsuit,they only look at the narratives and not the flowsheets,mars,etc. I was sent a letter by my agency that stated everything must be charted on the narratives even though we have flowsheets(double charting in my opinion) because in Nc other things aren't looked at.

This is in homecare.

[Flying ICU RN]

In some states,if there was a lawsuit,they only look at the narratives and not the flowsheets,mars,etc. I was sent a letter by my agency that stated everything must be charted on the narratives even though we have flowsheets(double charting in my opinion) because in Nc other things aren't looked at.

This is in homecare.

This is easily confirmed or ruled out with a little effort on your part.

I find it highly unlikely that the rules of evidence and discovery in any state would simply "throw out" flow sheet data in a malpractice case.

This sounds more like a personal preference being dictated to the rank and file.

[nursel56]

I've noticed a huge amount of variety and some rather odd practices in some home health agencies. Someone here mentioned they aren't allowed to use any abbreviations at all in the narrative - "alert and oriented times three" for example. That will make your narrative loooong in a hurry!

I know of no regulatory body requiring that. There are a few we've been told not to use such as "cc" and "DC", but I really can't see the purpose in disallowing common abbreviations.

[caliotter3]

Our agency put out the edict about abbreviations when JCAHO published their list of "Do Not Use" abbreviations back in 04. I just decided to start spelling everything out at that time to avoid being called into the office to redo notes. Of course, supervisors took it upon themselves to go further than the "Do Not Use" list and field nurses like myself just found it easier to stop abbreviating altogether. Problem supposedly solved.

[diane227, LPN, RN]

Most nurses learn to shorten their notes as they go along. It is no uncommon for a nurse who is using a flow sheet with check boxes etc to repeat that information in the narrative portion of the note. I find myself doing this from time to time because I HATE check boxes. I like to clarify what I do, see, and hear and I am very specific about documenting exactly what I told someone and who I told. Usually nurses are able to trim down notes over time as they gain more experience.

[MaryAnn_RN]

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.

I don't believe the internet is anonymous. Let me just say that it was a frightening, horrible experience, one which I would not wish on even my worst enemy. It wasn't my patient, I was the charge nurse.

With regard to people writing excruciatingly detailed narratives, I just don't have the time and wonder how they do.

We have to chart on the ICU charts as we go along, and then write a summary in the patients notes on the daily review sheets. I use a systems approach with headings and bullet points. Anything else not covered by that gets a brief summary. The only time I use a narrative is when documenting family discussions.

[mpccrn, BSN, RN]

I work with the newer generation of grads in the ICU and I see what some of them chart....it's amazing to me that they spend time charting 'PO meds given' on a routine med pass. WHY? They signed them off on the med sheets, yet they fail to mention the patient's heart rhythm. I don't get it. I'm all for covering your butt with your charting but a narrative note should be something not documented somewhere else (if it is indeed routine.) How did the patient respond to a new medication or treatment? They are paying extra for the cardiac monitor, acknowledge what is seen. What are their breath sounds? As you're weaning the vent, how are they doing? The narrative notes should paint the picture of events as the day progresses, not a place to write that you gave meds when you were supposed to. Short, sweet, pertinent...then you have time to turn and reposition, hand your patient the IS, and do some education.