Many nurses do not chart?

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Hey, I was just wondering. 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 am realizing that if I want to leave on time and stop getting in trouble for leaving late, I must leave a lot of charting blank. However, I feel extremely uncomfortable with this.. 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?

yes that is true but then I saw there was a miracle on our floor because a quadriplegic walked in his room for 1 CNA and the nurse confirmed it with her charting. but by the next shift alas, he was a quadriplegic again. this is very had to explain to the State during survey. also looks bad for the nurse and cna

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Specializes in IMCU, Oncology.

When I worked the floor, I charted at the bedside 90% of the time. I was a new nurse and left on time most of the time, I can think of 3 times I didn't. Older, more experienced nurses didn't chart until the end of their shift and left late every time. I think charting at the bedside when possible helped. I charted what needed to be charted.

Also I could copy the previous charting. I would also check it over and change appropriately, because their were times when an amputee had a pulse in a non existent appendage. But copying and pasting saved time!

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One of my professors was also an attorney who specialized in medical malpractice. She told us to "chart like you're going to court" so I do.

I think if you amend it to this: "chart like you're going to court.... for serious patient problems concerning life and limb."

"I know they can't breathe... I'm charting it right now!"

If I'm going to get sued because I did not emergently get Tylenol for a headache or a cough drop for a sore throat, then so be it. But I have confidence that it wont happen. (Now...if you ignore your patients pain for a whole shift, that's a different story...) I will also amend amended quote to include charting on patients or families with behavioral problems much more frequently and quote them in my charting.

Now consider the scenario that your patient has been declining all day, the MD doesn't make it a priority, and the patient eventually codes. Certainly now is the time to chart like you're going to court. State who you called, who you talked to, how you escalated the situation and whatever else you did.

But charting every single detail on your patients ad nauseam may not make you a better nurse and serve to make you stay late. For the love of Pete, some still chart on patients tattoos or old scars. What a waste of time.

Chart by exception. Copy forward only your own charting. Don't chart things twice. Notice things that are not WDL. Advocate for what is really important, right now. Guaranteed, you will at some point have to choose between patient care, or charting what you did.

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How do you reconcile "charting by exception" with "if it wasn't charted, it wasn't done."

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I think if you amend it to this: "chart like you're going to court.... for serious patient problems concerning life and limb."

If I'm going to get sued because I did not emergently get Tylenol for a headache or a cough drop for a sore throat, then so be it. But I have confidence that it wont happen. (Now...if you ignore your patients pain for a whole shift, that's a different story...) I will also amend amended quote to include charting on patients or families with behavioral problems much more frequently and quote them in my charting.

Now consider the scenario that your patient has been declining all day, the MD doesn't make it a priority, and the patient eventually codes. Certainly now is the time to chart like you're going to court. State who you called, who you talked to, how you escalated the situation and whatever else you did.

But charting every single detail on your patients ad nauseam may not make you a better nurse and serve to make you stay late. For the love of Pete, some still chart on patients tattoos or old scars. What a waste of time.

Chart by exception. Copy forward only your own charting. Don't chart things twice. Notice things that are not WDL. Advocate for what is really important, right now. Guaranteed, you will at some point have to choose between patient care, or charting what you did.

I figured charting by exception would be a given. Didn't think it was necessary to be that trivial.

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How do you reconcile "charting by exception" with "if it wasn't charted, it wasn't done."

Most systems have you do one head to toe assessment in a certain timeframe. Do one per shift, per patient, then chart only necessary items or change of status thereafter.

Example, patient has pneumonia: complete your necessary head to toe assessment, then focus on lung sounds, change in sputum output, etc thereafter. Basically, your're charting all systems as necessary each shift and charting thereafter based upon patients medical issue and/or change in status that was otherwise WNL.

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I have a lot of experience with not leaving shift on time due to charting issues. Two I will mention: My last job (I retired recently) was twelve years on an ortho/neuro/skin ailment hospital unit, primarily fresh post-ops. Immediately after report, I would begin my patient assessments. However, it was impossible to complete even a portion of this task, due to interruptions, usually because one of my other patients needed to use the restroom. One aide per the entire unit, if you were lucky. Nightmarish. Second, I was commended for my charting numerous times, but chided for staying after shift to complete them. However, I discovered a pervasive problem with several nurses who CUT & PASTED their assessments, many times copying old or outdated assessments! They got to leave on time! The computer program that made that all possible is named, "EPIC".

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Specializes in hospice, LTC, public health, occupational health.
Maybe I just need to find a job with the appropriate atmosphere/staffing? Its tough

Good luck with that.

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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.

What type of unit do you work in? In our rural hospital, I work ER, Med/Surg, Swing bed, and handle outpatient infusions and wound care, usually all on the same shift. What I think I've gotten really good at over the past 3 years is knowing when to chart a little and when to chart a lot.

Our swing beds are pretty stable, basically LTC rehab cases in the hospital. They get shift assessments, and I'd chart that I turned them, follow-ups on effectiveness of pain meds, behaviors, new problems, and the effectiveness of a new order, etc. If they should have gone home 3 days ago, they were fine and dandy the whole shift and nothing happens, the shift assessment is fine.

Acute care or post-op patients that have something go wrong require more documentation. I don't look at it as "covering my ass" as much as leaving a good trail for 2 shifts from now if the next shift omits something from report or if the patient needs to be transferred, I can give the nurse or doctor assuming care a clear picture of what happened.

Buy insurance to cover yourself for court, and then just do your best for your patient, and you'll sleep well at night.

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Your facility should have charting guidelines for you to follow. Many places chart by exception so that would include charting only when something goes wrong or is different from your patient's baseline. I have experience as an RN and FNP for over 25 years and I have been serving as an Expert witness for the last 16 years evaluating nursing care in multiple settings and defending nurses to prevent license suspension. I will tell you that excessive charting is not necessary, but your charting is more important in a legal setting that administrations/nurse leaders/professors would like to believe. The average case I receive reaches a courtroom in 3-5 years AFTER the incident occurred. Defending your nursing care by saying "my typical practice" is to do this or do that, does not meet the standard. You will need to be able to show that you adhered to the standard of care by documenting your nursing actions and assessments. I will agree that you do not have to have a narrative for everything and many things we do as nurses can be located in other parts of the chart, i.e. medication records, vital signs sheets, etc. Protect yourself, I have watched many facilities/administrations, etc. completely leave employees out in the cold when they are sued.

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Cut and paste should be disabled for charting. EPIC is not a widely accepted computer program in the medical legal field because of this problem. As an RN/FNP expert witness who travels all over the country evaluating and testifying regarding nursing care, I can tell you that I have seen many facilities get "popped" over cut and paste charting because a nurse decided to take a short cut. At the end of the day, your assessments should performed each time and no other nurse should 'want" to rely on another nurse's assessment.

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Specializes in SICU, trauma, neuro.
How do you reconcile "charting by exception" with "if it wasn't charted, it wasn't done."

Well what is "done" *is* that exception -- you still document any wound care, collaborative interventions, meds given, etc. If abdominal assessment is WNL, just click the WNL box, vs. writing out the "bowel sounds audible and normoactive in all quadrants, soft/nontender, contour unchanged from baseline, pt denies nausea/vomiting/pain. By clicking WNL you are acknowledging that you did perform the assessment

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