Many nurses do not chart?

Viviana, ASN, RN · Dec 6, 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.

You should always be sure to chart each and every time you page a doctor, as a CYA move.

NightNurse704 · Dec 6, 2017

I'm all over the map on this one. I see nurses at my workplace who are seated at the station, ready to give report and count narcs at 15 minutes to shift change. I used to wonder why I wasn't that fast. After my patients got to know me, they would tell me things like, "You're the only one who gives me my eye drops", or "You're the only one who checks my dialysis shunt". I had one blatantly ask me why no one else gives her her medications. I wouldn't throw another nurse under the bus, so to speak, but I'm no longer impressed with how "fast" certain nurses are with their med passes. As far as charting goes, I have to agree with the originator. Some nurses don't chart. Period. They will give you important information in their report, but nothing is ever charted. Or if you ask questions about a certain patient, you'll probably get a response like, "Oh, Mr. So and So? He does that all the time. He's just that way." I don't chart excessively, but I'll certainly chart to show that I noticed something, intervened and either got the desired outcome or passed the information to the oncoming nurse so he/she could monitor the patient. CYA. I'm convinced no one else will.

3ringnursing, BSN · Dec 6, 2017

Now that IS the conundrum, is it not? "If you didn't document it you didn't do it". We've all heard this phrase - from the newest newbie, to the saltiest and most experienced nurse (probably originating back from time immortal - when charting became a requirement, not an option, of nursing).

Gack!

My OCD brain says you shouldn't cut corners - that is until it's found itself stuck late charting with yours truly yet again ...

NICUMurse87, BSN, RN · Dec 6, 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!

I feel like we spent more time than necessary learning to chart in a system I never used again. Learning WHAT to chart I feel is more important than learning HOW to chart, since there are huge differences in the charting programs. For example, I learned Meditech in school and then Epic for work and learning Meditech was almost a hindrance to my learning Epic.

**NickiLaughs, ADN, BSN, RN** · Dec 6, 2017

The only notes I write: upon meeting the patient, of a major change happened to their assessment and interventions and finally handing off care. Otherwise it's just the assessment and scanning meds. None of which should take that long. I'm a firm believer in charting as you go. Tasks/chart. I don't just go from task to task unless it's stat. Maybe it's more of a time management issue?

cjcsoon2bnp, MSN, RN, NP · Dec 6, 2017

I haven't been a Med/Surg nurse in a while because I'm in the ED now and the charting requirements are completely different but my previous nurse manager regarded me as a pretty thorough in the documentation department and I didn't have to stay late in a shift to document very often. Here is what I used to chart on my patients during a given shift:

Initial Physical Assessment (Head-to-Toe) - Done at the beginning of the shift and completed using the template provided so if something was WNL (meeting each of the form criteria) then I would check that box and I would elaborate more on the systems that were directly affected by patient's problem (e.g. COPD Exacerbation - Cardio, Resp., Appendectomy - GI, Wound etc.). I don't repeat a physical assessment unless something changes during my shift. In this template we had sections for Fall Risk, VTE/DVT Prophylaxis, Braden Scale etc.
Progress Note - Our hospital's policy was that if you worked an 8 hour shift then you only needed one physical assessment note for your patient but if you worked 12 hours then they needed some form of progress note or reassessment after 8 hours. I made a generic note that briefly described that the patient's condition that I was continuing care of the patient and the patient's physical assessment remained was unchanged from my previous note unless otherwise noted. If at any point the patient had a physical change (e.g. New onset of chest pain or abdominal pain with vomiting) then I would open up the physical assessment template for that specific system (cardio-respiratory, GI etc.) and check the findings along with write a comment of the interventions. If it was a complicated situation or had a lot of interventions I would write a progress note instead and put the physical assessment findings in that instead. I would only write a progress note if it was indicated, if I worked 8 hours and the shift was unremarkable then I wouldn't write it.
Medications/EMAR - I would chart in our EMAR by scanning the meds. I don't re-write them elsewhere, if I need to say a patient refused or something special then I can add it as a comment in the EMAR for the medication in question.
Care Plan - Our facility required us to write on the patient's care plan each shift. I found many nurses didn't do this because they found it to be redundant and a waste of time (I personally did not find it very "value add" documentation myself but I just wanted to follow the rules). I tended to be brief in the care plan and use the template provided to make it faster.
Physician Communication or Critical Lab Value - There was a section in the chart for each of these and it was pretty
I&O - If I emptied a urinal or admin. IVF then I would add what I needed to at the end of my shift based on a list I made. This was a shared task with the CNA so sometimes it was just me verifying/double checking that it had been completed.
V/S - Similar to I&O this was a shared task with the CNA, I would write them if I took them myself but if I didn't then I would simply review it to make sure nothing was abnormal or need to be rechecked.

That was my list of required documentation, I did not write a generic progress note that summed up the entire shift because I found it repetitive of the other documentation and it was not mandatory on our unit. When I was writing on the patient's care plan I would tend to include a few brief statements that could be described as a form of shift summary and gave a similar feel to the traditional end of shift progress note. I realize that physicians, case management and everyone else on the team enjoyed having the narrative progress notes that summarized the entire shift because it was easier to find the information (and I honestly liked reading them as well). However, with all of the additional requirements in documentation added to nurses over the years I don't have the time to do something if it is (a) not required per my hospital's policy and (b) if I have already included the same data elsewhere in the medical record (even if it requires a few more steps to find each piece). If our manager had reinstated the end of the shift progress notes or I hadn't chart something elsewhere in the record then I would happy to create a generic progress note.

Lastly, here were a few other tips I found helpful.

Using the WNL feature of the physical assessment form/template - I say this with caution because you need to make sure your template/form/checklist has a clear definition what WNL is for each category and you need to read through it carefully before you check it. Don't be the nurse that checks WNL under the peripheral vascular or musculoskeletal sections for a patient who is a bilateral below the knee amputee, you will look incompetent, lazy or inattentive. If you don't have a template/form within the chart that clearly defines WNL for something I would suggest you use that phrase carefully because you may need to be able to define the parameters of "normal" in your charting if you were ever to be audited..
Don't repeat the same thing 100X - I see a lot of nurses re-writing the V/S or meds. given in 100 different places on the chart and I don't understand why. If you are writing a progress/event note for a situation that required repeat V/S and med. administration you can write [see Vital Sign Flowsheet] [see EMAR] and that is appropriate.
Give yourself time - This means give yourself time to learn what data is the most relevant and to refine your note taking ability. This also means to try to coordinate your shifts to give yourself plenty of time to write if you're someone who takes a long time to write. I agree with the other user who said many times the people staying late are the nurses who either write too much, talk too much, or struggle to plan out their time in the most efficient manner.

I hope this helps!

!Chris :specs:

she244 · Dec 6, 2017

I took a class a while back on Legal Medical Documentation. I learned a lot about charting. When 2 much charting is just as bad as not enough. As a nurse most of us know what is crucial to patient care and what the Physician will be looking for when he reads the chart. It would be helpful to take one of these classes if you can. I stay in touch with the lawyer who taught the class and it is amazing the errors she finds in charting that helps her win her cases.

marylou5 · Dec 6, 2017

If you didn't chart/document it....you didn't do it! Count on it!

That's what your charting reveals to everyone ...especially the Courts!

Keep charting as you have been, while critiquing yourself whether or not you are long winded and how to make your comments more concise. If you follow through on an MD's order..chart it..ie IV started or discontinued. Don't short-change yourself or your pts.

Clear, concise charting documenting what you did/observed etc will never get you in trouble. CYA!!!!

I/O, Vital signs, bed sore descriptions/measurements, RXs etc etc etc...not charted are considered by courts as not done!

Like you I left late to document what I did...it is what it is! Documenting what you did is mandatory..just do it!

I've called too many nurses, when a patient had an emergency and needed info for an MD, and nothing was charted...and yet the nurse had witnessed events/ symptoms she did not bother/forgot/was going to chart a late entry tomorrow! Shame on them (and now I have to write an incident report as well as everything else..because the MD is livid the info was not available!)

sunny time · Dec 6, 2017

just the facts without being long winded. for example.pt had an episode of SOB crackles noted upon auscultation. dr so n so called for order HHN with albuterol 1 unit. tx given with expulsion of yellow thick mucus. auscultation of lungs post treatment showed diminished on left lower lung field. O2 say 94% on 3l O2.

Kooky Korky, BSN, RN · Dec 7, 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/surg 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.

time mismanagement is not always the problem.

There's only so much that can be managed in a given amount of time.

OP, chart shorter narratives if you chart narratives at all.

Chart only for problems.

For example: pt c/o SOB; wheezing and rhonchi noted bilat LL; resp 30/min, O2 Sat 84%; Dr. Smith notified, orders rec'd; chart the temp and whatever other VS you obtained.

After you have carried out the new orders and rechecked the pt, write:

CXR done, shows pneumonia per hospitalist Dr. Andrews; antibiotic started, chest PT done, (add whatever O2 supplement pt is now on, type of mask or whatever); resp 22, less labored and other VS, like a temp; family (name) notified, says will visit tonight; (This is for LTC, where families are notified for changes).

I used to be the last one out, staying late to chart, not having taken any breaks. I checked my CNA's charting of I&O's, wts, etc. The other nurses had not only meal breaks but smoke breaks. Guess what - they didn't check their aides' charting and they barely did their own charting. They also never called a doctor for problems unless someone was literally dying. If you noted problems and didn't leave them for a doctor to see the next day, you got behind. Never mind that the pt was suffering with a sore throat or something painful but not life-threatening. It takes time to get orders for gargles, lozenges, sprays. Not getting the orders means your pt will be uncomfortable. Can you live with that? If you want to get out on time, you might have to just pass that stuff on in report and hope it gets addressed on the next Rounds. ( If it was a decent hour, I would call for stuff like that.

Late evening, midnights - let Docs sleep.

Their key was to make sure the med and treatment carts were restocked so the nurse following them couldn't c/o that. They charted their meds and did the minimal charting required. They got out on time.

Good luck. You should read some of your colleagues' notes to see how they chart. You can learn.

hihorse · Dec 7, 2017

Are not the I's and O's charted on the face sheet ----I chart a lot because I am a mental health nurse I talk to the pts, there are nurse who do don't chart as much as I do but I want anyone that reads my note to know what is happening----I just learned to type fast, and try to have a system to my charting so that I can get done, if you have a system of how you chart you might be able to chart faster.

sunny time · Dec 7, 2017

it is hard to believe you could chart and get out in time as wordy as you are