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My rule is that nursing is all about prioritizing, if charting isn't more important than care which needs to be done then I provide nursing care first, whatever charting doesn't get done just doesn't get done. I do make sure I chart things that do actually directly affect patient care and safety such as what meds I've given, relevant vitals and assessment, but I often just put in my note "note is the only routine charting entered due to workload prioritization".
I chart in the room when I can. It helps me spend time with the patients and if they want to chat, and don't mind me multi-tasking, I can chart on more than one pt. We had a pt with post-op delirium exacerbated by Parkinson's so we took turns sitting with the pt (as no sitter was available) charting and engaging him. It is fairly easy to do. If I don't get everything charted, I tell my oncoming relief and apologize. I make sure to get the important stuff done (I&Os, clear pumps, assess incisions and dressings, VS) .I try to make pt care a priority.
I can't believe these people... at my job "oh sorry I didn't have time to chart" doesn't cut it. Charting is a REQUIREMENT and if we don't do it to the letter we get written up and even fired. I'm supposed to leave at 7:15 and I stay until after 8:00 almost every night to finish charting, I've even had to stay as late as 9:20 before! We have an insane amount of charting on every single patient and none of it is optional!
I can't believe these people... at my job "oh sorry I didn't have time to chart" doesn't cut it. Charting is a REQUIREMENT and if we don't do it to the letter we get written up and even fired. I'm supposed to leave at 7:15 and I stay until after 8:00 almost every night to finish charting, I've even had to stay as late as 9:20 before! We have an insane amount of charting on every single patient and none of it is optional!
That's the nice thing about working in a state with legally prohibited mandatory overtime for nurses. Nurses can't be required to work beyond their scheduled time including to finish charting with a few exceptions; charting to avoid imminent harm, such as what medications a patient did or didn't get and acute changes, all other routine charting can be left undone and your employer is legally prohibited from enacting any punishment or other action for failing to finish charting.
I find myself pretty anxious at the idea of leaving charting undone. There is some charting that I resent (i.e. charting that I received report, checked the patient Q1H, managed restraints Q2H, turned Q2H) but most of that is absolutely required. I remember a situation where my supervisor from when I worked on a Post Surgical floor received a complaint that she'd "never been educated" about how to manage her new diagnosis, surgery, etc. This patient just happened to have a nurse that was notoriously detailed in her charting and -- guess what -- she had been educated. She'd also been pretty resistant to the staff. lol It wasn't enough to go into being a litigious situation but I was glad to hear that outcome. Now that I'm in critical care and my patients have so many different specialists, I chart extra to make sure everyone knows about any changes in status, family concerns/dynamics or any potential problem areas, as well as the usual CYA charting. I rarely leave right at 7:30pm but it's only on particularly crazy days when it is as after 8pm. I know some days on the floor were worse.
Ms.muhammadRN
1 Post
I feel like the art of bedside nursing is being totally compromised by the overwhelming amount of charting. No real time for bedside nursing...I have got to chart.