Many nurses do not chart?

Sour Lemon · Dec 4, 2017

There are nurses who chart repetitively and excessively. When they give a medication, they have to write a narrative note although it's all recorded in the MAR. When a patient vomits, they have to write a narrative note although it's recorded in the assessment. When they get a new order, they have to write a long, rambling, narrative note although it's obvious that a new order was obtained due to the new order, itself. Those are the nurses I observe leaving 1-2 hours late every shift. I think they're nutty.

macawake, MSN · Dec 4, 2017

On my unit I leave late every shift because of charting. The other nurses always leave on time, and they leave A LOT of charting blank.

I do SO MUCH work through a shift and I want it all charted. What if I go to court one day and it looks like I did nothing my whole shift?

I have had 5 jobs and they are all like this. Any feedback?

(my bold)

Reading your post I have to wonder if perhaps you chart excessively. You say that you've been leaving late at all five (!) places of employment and that everyone else in all these places managed to leave on time. I find it hard to believe that every single nurse you've worked with has failed or fails to chart appropriately.

I think your fears about that day in court might be somewhat exaggerated. I'm not a U.S. nurse so I don't know this for a fact, but I would expect that you wouldn't have to account for every single minute of every shift if you ever have to testify. I would assume that you would need your charting to support/show that you did the relevant/appropriate things for that specific patient and situation, but not every single thing done or every single word uttered, in the shift.

Is there someone you can ask for advice and who might be able to tell you if you do indeed chart in unnecessary detail?

Good luck!

Those are the nurses I observe leaving 1-2 hours late every shift. I think they're nutty.

Nutty's a bit harsh I think a lot of it is anxiety. Sure, some people are just naturally long-winded, but I do think worry is often the root cause. I remember when I was a new/recent graduate, I certainly charted more out of fear of omitting something relevant. My charting is much more focused and bare-bones today :)

Guest716906 · Dec 4, 2017

I Know What You mean, I Do NOT chart like that. I simply chart the things I feel are very important, I&O's, turns (in real time) 1 reassessment. And notes abut when I clarify something with a Dr that they don't have to put an order in for. And I always leave late. The nurses who leave on time leave I&Os blank and leave talking to the doctors blank so I have to reclarify, and leave reassessments blank. I want to do the same but get scared "what if I go to court"

Sour Lemon · Dec 4, 2017

I Know What You mean, I Do NOT chart like that. I simply chart the things I feel are very important, I&O's, turns (in real time) 1 reassessment. And notes abut when I clarify something with a Dr that they don't have to put an order in for. And I always leave late. The nurses who leave on time leave I&Os blank and leave talking to the doctors blank so I have to reclarify, and leave reassessments blank. I want to do the same but get scared "what if I go to court"

Have you asked anyone you work with who has access to your charting to critique it? It's difficult to give feedback on something that cannot be observed.

If you hit the "quote" button in the lower right corner before replying, people will know who you're replying to.

Is and Os are not meaningful for every patient. That's another thing I see nurses staying late to "accomplish". And most of the time they're estimating, so their numbers are inaccurate. I do them when the matter and when I can document accurate information. It's a waste of everybody's time to bother, otherwise.

Guest716906 · Dec 4, 2017

I guess I probably do over chart. I feel like I have gotten dinged for charting so much in the past that it's ingrained in me to chart everything.. "this MD will be mad if I don't chart this, manager will be upset if I don't chart that, if I go to court it will look like I didn't do it". It's just getting too much. Do you know of any person I can go to and ask what is necessary? I can't even tell anymore.

Sour Lemon · Dec 4, 2017

I guess I probably do over chart. I feel like I have gotten dinged for charting so much in the past that it's ingrained in me to chart everything.. "this MD will be mad if I don't chart this, manager will be upset if I don't chart that, if I go to court it will look like I didn't do it". It's just getting too much. Do you know of any person I can go to and ask what is necessary? I can't even tell anymore.

I would ask someone at work who seems "together" and see what suggestions they might be able to offer.

guest52816 · Dec 4, 2017

Where I work, we are told we must chart certain things, such as each time we pick up the phone and notify the MD of something, or request medication, etc.

I only write long, narrative notes on patients who either had a dramatic decline, or family issues, or something else out of the ordinary. Otherwise, those notes are short, and to the point.

A rule of thumb that I have been told is: Chart the things that would cause a court to ask, What did you do about this?

Having said all this, we all got an e-mail last week stating that some nurses aren't charting properly and leaving items blank!

I don't think I am one of those nurses, as the NM stated that she had already spoken to some people about the issue. But, who knows. It was a vague e-mail.

I am sure this is a common problem among nurses.

Guest716906 · Dec 4, 2017

I think I am realizing that we learned nothing about court/defensive charting/ the legal system in my nursing school. I used to just chart what I thought was relevant. As the years go by, I have gotten dinged for things/managers keep adding small random things we "have to chart". Makes me wonder have I been doing this wrong all along? Why do they make a big deal out of this.. aren't focused charted assessments more important? (Frustrated)

guest52816 · Dec 4, 2017

You are right, nursing school teaches nothing about charting. And I am recent graduate (May, 2016).

We spent time learning how to do hospital corners (with sheets), even though hospitals use fitted sheets, but no time on charting!

Guest716906 · Dec 4, 2017

You are right, nursing school teaches nothing about charting. And I am recent graduate (May, 2016).
We spent time learning how to do hospital corners (with sheets), even though hospitals use fitted sheets, but no time on charting!

Oh my gosh thank you. I feel so alone anymore! Nurses get in trouble for everything the longer I am in the field. I feel like I'm the only one who has my back so I chart everything. And stay later :/ I probably just need further education and maybe try a new unit.

blondy2061h, MSN, RN · Dec 4, 2017

There are nurses who chart repetitively and excessively. When they give a medication, they have to write a narrative note although it's all recorded in the MAR. When a patient vomits, they have to write a narrative note although it's recorded in the assessment. When they get a new order, they have to write a long, rambling, narrative note although it's obvious that a new order was obtained due to the new order, itself. Those are the nurses I observe leaving 1-2 hours late every shift. I think they're nutty.

This. When I was a floor nurse I did my check box flowsheets accurately and in real time. I wrote a narrative to document calling a provider about something. Our assessment flowsheet had a section for that- provider name, reason for call ("Critical pottasium reported"), outcome ("see new order"). Many nights I didn't do any other narrative charting. Right after receiving report I would assess my patients and have assessments done by 8:30pm. I charted my assessment on my COW right outside their room often before even moving onto my next assement, which meant I didn't need to worry about confusing assessments in my head. I read the paragraphs some people write and it doesn't make sense to me. It makes sense if I have a belligerent patient refusing everything and then blaming me when they're not well. It doesn't make sense if I have a patient taking all prescribed meds and following the expected path a patient in their shoes follows. I used to wait to chart on everyone at once. The energy I put into distractions and thinking back made it take much longer.