Majority of a Nurses Job is Charting? What is your day like?

PAERRN20 · Jul 12, 2009

I would say that many nurses don't spend most of the day charting. My day is spent giving meds, doing procedures, talking to doctors, wound care, and running around like crazy! Charting usually is squeezed in there somewhere. It would be heaven if I could sit at the computer all day and chart but alas that is not what happens! Nursing is much more than paperwork. It's all about the patient, and managing to fit the charting in.

It really depends on the area of nursing but I think most nurses would say charting is difficult to fit in at least occasionally.

onetiredmomma · Jul 12, 2009

when I did homecare, paperwork was definitely my biggest task. But I would say that charting is a big necessity of a nurse's job in the hospital enviornment but nowhere near the biggest time user! Pt care and the related tasks as PAERRN stated uses 99.9% of my day...gotta fit that pesky documentation in somewhere!

RNperdiem, RN · Jul 12, 2009

Charting does take time, but not the majority of my time.

I can do vital signs and a head to toe assessment of a patient in 5-10 minutes. The computer charting of my assessments and vitals take about 10 minutes.

In some settings, it is difficult to go 10 minutes solid without some type of interruption.

So after I answer the phone, check the alarm next door or finish what distracted me, I finish up my charting. The frequent interruptions make charting seem like a neverending task of catching up and staying ahead.

Restrains require charting every 2 hours, a narrative note gets written once a shift for each patient, head to toe assessments are charted every 2-4 hours in ICU. There is a lot of data to put in.

mzjennx, BSN, RN · Jul 13, 2009

charting covers your a$$. bascially if it is not written documented, then it means you did not do it. so if you have to overchart, then do it. I think I chart most of the time and chart after I something, so I wont forget. some people pre-chart before they do it, I think this is wrong. i rather chart after i do it asap, so i wont foget.

SunnyAndrsn · Jul 13, 2009

Today was a particularly heavy day of charting for me, I work in an LTC/TCU, and had 22 TCU pts. It was two CNAs, a TMA, and myself. Nine diabetics, lots of treatments including trach cares, two JP drains to manage, a J-tube, a G-tube (that was leaking), a pt. that needed to be sent to the hospital, a PICC that was pulling out, surgical wounds to check and re-bandage, 9 medicare VS and a fall follow up. I also had a lymphedema pt. that needed to have her legs washed, lotioned, and re-wrapped. We also have a number of pts. with behaviors, and I was responsible for a hospice pt. who is rapidly declining. To add to all of that, I was charge nurse for the facility, including the LTC wings who had two other nurses. One had a new pressure sore that I had to stage and assist with documentation.

I was scheduled for 7 1/2 hours (6-2, supposed to have a 30 min. break HAH!) and I ended up working 9 hours and 15 minutes. Three of those hours were charting and signing out documentation. The rest was all hands-on care.

ChristineN, BSN, RN · Jul 13, 2009

I do tend to spend frequent time charting, since in my pediatric facility we are supposed to chart on our patients at least every four hours. Depending how the day is going, sometimes I can chart as I go, and sometimes I'm charting 12 hr's worth of charting in the last couple hours of the shift.

NeoNurseTX, RN · Jul 13, 2009

If I could just DO and not chart, I'd soooo love my job.

nursej22, MSN, RN · Jul 13, 2009

I estimate that charting takes close to 50% of my time: head to toe assessment, VS, EKG strips, IV sites, blood glucoses, pain scale, Braden scale, fall risk, any titrated gtts, medications including who you double checked heparin and insulin with, any treatments, calls and/or conversations with docs, care plans, any education done with pt or family, discharge planning, checking off tasks on the electronic Kardex (i.e. safety checks, hygiene, activity), and checking off orders.

With our cr@ppy computerized chart, I have to duplicate much of what I do on paper because of how difficult it is to retrieve the info, at least for the clinical staff. Most of the computerized stuff seems to be for auditing, not for actually improving pt. care.

I work on a telemetry unit with rapid pt turnover (75 to 100% in a 24 hour period), so included with the usual charting is admission and discharge documentation.

nervousnurse, ASN · Jul 13, 2009

Ughh.....unfortunately where I work, they think it's the 1950's again and we HAVE to do a lot of NARRATIVE charing!!:angryfire

OMG, and don't EVEN get me started on the MULTITUDE of paperwork for a new admit!!!! :cry:

ANDDD............since Medicare stopped paying for things like UTIs, decubs, falls....what else......we have to document

even MORE.......

We USED to have a modern "flow sheet" for our head-to-toe assessment, now they changed it to a TERRIBLE new

form, and ALL OF US are ALWAYS late getting out because of that, AND the required longggggggg, narrative entries

that have to be made q 2 hours. OMG, we are NOT even allowed to chart "Apical pulse RRR" anymore!!!:angryfire

Nope, gotta actually write "regular rate and rhythm"....(and the word "rhythm" is always tricky to spell!!!)

Can't even chart "AAO x 3" either......OMG, we are ALL mad, the higher ups KNOW we're mad, and they also don't

bug us about clocking out up to TWO HOURS LATE because they KNOW we don't have time for that charting DURING

the shift!!!!!

They SAY we're going to go to computer charting "Sometime"....but we are NOT holding our breath! Do I want to

find a new job? YES, and for many other reasons than just the charting.....but I am finding out that jobs DONT come

as easily as I thought they would