We are now required to chart all meds given IV, IM, SC, in addition to Mar, and nurse notes. I know it's a new policy, I don't like it, but I will adapt. It takes an enormous amount of time. One of my pts received lasix, solu medrol, two antibiotics and IV flds, all at the AM med pass. Each of those meds had to be hand written out on a form, in addition to signing off the MAR. Our charge nurse told us it was a new medicare requirement. We are usually behind times where I work, and the rest of you may already be doing this extra charting. Does this sound familiar?
Staff has been cut to save money, and now we have this time consuming new requirement that is stressing me out. Do any other nurses have these new forms?
we use the electronic emar system. that is a one time process. thank heavens. you scan the pts wrist band, the medications, and then thats it. the only other time you chart medications is perhaps a one time order or stating the pt was medicated for pain.
now this is the way to do it. the nonelectronic version is to sign the mar, once, and once only, unless something unusual, a pain med, or a psychotropic.
Double charting drives me BATTY!!! We're supposed to chart our accucheks, even though when we dock the machine, it sends the results to the chart anyway. All I can imagine is going to court, and having to explain, "Well yes, I did type in 77 and the accucheck was actually 74. Yes I'm a horrible nurse that can't even type the right number."
And why is it that the only solution to every Medicare/Medicaid/Joint Commission/Press Gainey/whatever problem is for the nursing staff to chart even more? Just once, when they find out the new "changes" for the year, couldn't they decide, "Well we don't actually NEED to chart this!" And it's always something that "only takes a minute more." Of course, multiply that minute by the times they've added other things that just take "only a minute more," and then multiply that by how many patients!
The only thing in my hospital that is charted x3 is tissue implantation (because of the liability and tracking). Not only is charting the same event multiple times time consuming, discrepancies are a legal liability when and if they occur.
Specializes in Management, Emergency, Psych, Med Surg.
I do not do this. I refer them back to the MAR. I then make copies of all these forms and write a formal letter to management asking why it is expected that we document in three different places. This usually occurs when managers make up documents to meet some criteria set by JCAHO or the State without already knowing where this information is already documented. This is why, in a good, functional organization, you ask the NURSES to fix these problems. Ask the nurses how to fix these issues since they will be using the forms. I absolutely refuse to document anything twice.
All this extra charting has just go to the point of being ridiculous.
I can honestly say, if I have 6 patients with some who are demented/palliative or who demand extra attention, that I cannot give it because I am too busy with paperwork.
I will not chart anymore than once. For our schedule 8 meds, 2 people check them and sign the drug book (federal law in our country). I write given for whatever in the nursing notes, that's it.
I don't honestly know what these managers think we do with our time! Tell your managers you aren't doing it. Get everyone else to stand up to them, unless it's a federal law I would not do it - patients come first, and as long as a drug is charted as being given (electronic or however), it is recorded somewhere.
You will just get depressed and stressed having to do all this extra work.
Whatever extra work will they want nurses to do next?
Specializes in Management, Emergency, Psych, Med Surg.
We had the same issue come up several months ago and when they were giving the inservice on this issue I pointed out to the education department where this information could already be found on the record. I reminded them that by adding another form, compliance would decrease. They did away with the new form because they had failed to look at the old form to find out what we were already charting. The new form had been developed as a response to a department of health complaint. There is always a reason that they come up with this stuff.
We had the same issue come up several months ago and when they were giving the inservice on this issue I pointed out to the education department where this information could already be found on the record. I reminded them that by adding another form, compliance would decrease. They did away with the new form because they had failed to look at the old form to find out what we were already charting. The new form had been developed as a response to a department of health complaint. There is always a reason that they come up with this stuff.
Yes Diane, there is a reason they come up with this stuff. It's called 'covering their own a***s'.
Management only care about patient safety in regard to law suits, & if you get in the way, you go out the door.
caliotter3
38,333 Posts
now this is the way to do it. the nonelectronic version is to sign the mar, once, and once only, unless something unusual, a pain med, or a psychotropic.