Many nurses do not chart?

Guest716906 · Dec 4, 2017

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.

I actually just realized that the 1 job where I had a cow I would get charting done faster. I think when the computers are in the nuses station you HAVE to wait too long. And no NA means assessments take that much longer. Maybe I just need to find a job with the appropriate atmosphere/staffing? Its tough

LovingLife123 · Dec 4, 2017

I very rarely enter additional notes about my day. I check my boxes and get done. Does your unit not have a standard on when and how often things are to be charted? I often notice notice that the previous shift nurse charts way more than what is required.

I don't know your charting system, but we only the chart the abnormals. I do three, head to toe assessments each shift. In my early one, I only chart the abnormals. In my other two, I only chart the changes.

I work in an icu so certain things like vitals and I/Os get done hourly. I never put in any word charting on meds. If I give it, it gets scanned, all done. If I hold it, I tick the appropriate box as to why.

Find out your unit standards. There should be some in regards to charting and use that as your guideline. It sounds like you are over charting. That can get you in just as much legal trouble as undercharting. Some people don't get that.

cleback · Dec 5, 2017

I would generally agree with you... I myself just had a patient the other day that went from room air to bipap and in restraints in the previous shift without a darn thing charted.

However, if all five jobs are having you stay late, I would suspect something could be changed in your own practice. I like the previous posters suggestion of having a trusted colleague review your notes. Best of luck!

Double Dunker · Dec 5, 2017

Do you have a unit educator you ask about charting?

mushyrn, BSN, RN · Dec 5, 2017

I feel this is more related to you "over-charting". I am always finished charting by 6:30 before shift change. I also try to chart as I go, which is generally feasible. If it's a particularly busy day, I will do the patient care and if it's pertinent, I will chart it before I leave the room so that nobody in the hallway can distract me from doing my job. If I get a call, "sorry, I'm in a room".

Some of my coworkers stay over HOURS charting... I often find it's either because they chart too much, read too much, or talk too much. That being said, I talk a lot at work, but I make sure my charting is done around that talking. Some nurses literally read through the entire health record from day one in ER... who has time for that?

Your unit should have standard charting guidelines. A lot of it is common sense. Look at other people's charting, see what works and what doesn't. Include pertinent events. Look at the physician's charting and how their styles differ between providers. You have to find a style of charting that works for you, catches the important information, and ignores the useless stuff like the patient's dog's name or which toe is shorter than the rest.

Purple_roses · Dec 5, 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"

I think you're charting correctly. Do you save all of that charting for a certain time of night or do you try to get it done right after the situation happens? If I wait to chart narratives, it takes longer because it isn't fresh on my mind. It might help to talk with your manager about charting expectations as well...I did this and found that we're only expected to chart by exception instead of filling in every single detail for the assessment. That definitely saved me lots of time!

applewhitern, BSN, RN · Dec 5, 2017

We chart "by exception." We can check (all computer charting) a normal assessment, or we can simply check the abnormals. I have to say, my nursing school dealt heavily with charting. We were constantly told what and how to chart, in case we ever went to court.

jennylee321 · Dec 5, 2017

For me, starting my narrative notes early is what keeps me from leaving late. I try to start them anywhere between 5-630 depending on the day.

I don't mention anything about my assessment unless it's really abnormal or it caused something to happen in the shift. ie. Abdomin noted to be distended at 1200, MD notified, put NPO and abdominal X-ray completed at 1300.

For those of us in peads especially, including information about family interactions is important but it is easy for this to become a time suck on charting, you look down and realise you've rambled on for a paragraph. When I write about the family I ask myself, "Is there a concern that needs to be documented?" "Is this information going to be useful to the next RN or SW?"

AutumnApple · Dec 5, 2017

I used to supervise on night shift at a nursing home. I saw charting deficits that would make most alert&oriented nurses facepalm. One nurse felt "Pt. coded, sent to hospital" and absolutely nothing else was perfectly fine documentation after a patient went into respiratory distress and 911 was called. I'm so grateful I was not working that night. The patient did not make it and, well, you can imagine the outcome after management saw her documentation.

On the other hand, as has been stated already, there are those who love to hide behind the computer and (cough) document all day. I don't know what they were documenting because they never left the nurses station to do anything. And of course we had the ones who'd spin around in their chair after report and start documenting their pt assessments. Never saw such detailed assessments as those done by the ones who never left the nurses station.

Point is, documenting is a part of what you do. Like everything else, it must be prioritized into the day. Over documenting, lacking in documentation, it's all the same thing. *But*, the problem is rarely the documentation itself per se.

You said you do so much work that when the time comes to document, you end up leaving late. I'm going to disagree with my peers here and say your problem isn't likely to be over documenting. I'm more inclined to believe it's time management and taking control of your assignment during the day that is your problem.

I see it like this. If it takes an hour per day to document properly, but you're running in circles with other things and leave yourself only 15 minutes to do it, you'll get out late. Most of the time when I see people getting out late, yes, they are sitting at the nurses station documenting. But it's not the documenting that made them stay late. It was mismanaging the med pass and/or other things that caused them to put off documenting until the very last minute.

Unfortunately, there is no magic wand to wave to make you suddenly able to improve here. For all I know, you may be a speed queen in completing your tasks and manage your assignment beautifully. Often, problems like yours are the result of poor staffing and over sized assignment loads. So there really is no place to improve on to fix the problem unless you are willing to sacrifice quality care for speed.

Welcome to nursing.

I did Med/surge my first five years in nursing. I faced this problem as well. As time passes, your view on what is a "priority" and what is not will change and how you manage your assignment will change. It will also start to include you getting out on time as a priority. But this part of the journey in nursing can't be "taught". It's very zen like. You experience it and you find your way.

JadedCPN, BSN, RN · Dec 5, 2017

I actually just realized that the 1 job where I had a cow I would get charting done faster. I think when the computers are in the nuses station you HAVE to wait too long. And no NA means assessments take that much longer. Maybe I just need to find a job with the appropriate atmosphere/staffing? Its tough

With all due respect, you've had five different jobs and its always been an issue - seems like the issue is likely you and the way you chart/what you chart, not that you aren't in the appropriate atmosphere/staffing.

ruby_jane, BSN, RN · Dec 5, 2017

Your BON requires certain things: if there's an abnormality (fever, pain), what was done, and was that action reassessed in an appropriate time?

We have some click charting but mostly narrative. At my last job it was all hand-written narrative!! Do you have a way to cut and past a template into the narrative boxes? That way it will cut down on the time you're taking to write it and you can still personalize.

I attempt to avoid charting on something I've clicked the answer to already. Having said that, your charting needs to provide the story about what you did and why. I agree with the previous posters that perhaps someone on the unit could provide some guidance. Finally, never, ever worry about what other nurses are doing unless they're creating an unsafe environment.

decembergrad2011, BSN, RN · Dec 5, 2017

Sorry if I'm stating the obvious, but is there a policy to follow at your institution? For example, I work in progressive care with telemetry patients and our charting requirements are different than those of the acute care floors, but also the ICUs. I would look for this policy and follow it for your basic guideline for your daily shift charting.

When there is a decline, a change, or even if I contact the doctor and it's not obvious that any action had been done (i.e. sys blood pressure is getting close to 180 but doctor just wants to recheck in an hour and continue monitoring for now, so there is no new order in place) I make sure to chart my action because I want to make it clear that I was aware and took action. Sometimes this is lengthy or requires going back and documenting every time I notified a doctor to establish that I was appropriate in following up, but that usually is for extreme circumstances.