Nurses Deleting Orders to Reduce Charting

[SilverBells, BSN]

At my facility, we have two areas of charting--the MAR and the TAR.  The MAR is obviously for medications.  The TAR is for treatments and other orders such as vital signs and when to notify the provider.  Lately, I've been finding that nurses are deleting orders from the TAR that they don't agree with or because they want to reduce the charting workload.  Problem is, they're deleting orders such as to document daily wound notes that are needed to monitor a patient’s conditions.  I've also noticed that the nurses deleting orders are those who generally dislike charting to begin with, so it's not really surprising they're getting rid of orders.  

What would your approach be in resolving the issue? I don't want to stir up drama but the orders were entered for a reason

[macawake, MSN]

9 hours ago, SilverBells said:

At my facility, we have two areas of charting--the MAR and the TAR.  The MAR is obviously for medications.  The TAR is for treatments and other orders such as vital signs and when to notify the provider.  Lately, I've been finding that nurses are deleting orders from the TAR that they don't agree with or because they want to reduce the charting workload.  Problem is, they're deleting orders such as to document daily wound notes that are needed to monitor a patient’s conditions.  I've also noticed that the nurses deleting orders are those who generally dislike charting to begin with, so it's not really surprising they're getting rid of orders.  

What would your approach be in resolving the issue? I don't want to stir up drama but the orders were entered for a reason

Ha ha SilverBells, you are incorrigible ?

I’m curious to see how many posters will take this seriously and also be suitably offended from hearing about nurses who to such an astounding degree appear to lack integrity or even a semblance of professionalism..

I am sooo fed up with having to change the CO2 absorbent all the time and having to chart about it (every single time!!) ? that I think that I’m going to introduce a new regimen.. Scratch propofol, remifentanil and sevoflurane.. Too much charting required. Instead I’ll serve my patients a cup of soothing chamomile tea and rub some lavender oil on their ear lobes (and obviously NOT chart about it.. duh!) 

I’m sure my manager won’t mind or at least allow me to continue in order to not stir up drama. (I’m not too sure about the surgeons though.. they might opine about my novel practice…) 

SilverBells, what should a manager do (in your opinion) if one or several employee/s  don’t do the job they are paid to do, and manage to endanger patient safety and outcomes in the process?

I’m no expert on the legal ins and outs regarding deleting patient’s orders… but I’m thinking it might be.. ahem… problematic.. Perhaps the correct course of action for a manager who finds out about these shenanigans… isn’t to consult the internet.. but to act in a time-sensitive manner.
 

[hppygr8ful, ASN, RN, EMT-I]

On 12/8/2021 at 8:40 AM, macawake said:

SilverBells, what should a manager do (in your opinion) if one or several employee/s  don’t do the job they are paid to do, and manage to endanger patient safety and outcomes in the process?

Sounds like a case for progressive discipline!

[NICU Guy, BSN, RN]

10 hours ago, SilverBells said:

What would your approach be in resolving the issue?

Instant termination. This isn't a case of discontinuing an order that is no longer relevant. They know exactly what they are doing. If you do not realize that these obviously require disciplinary action, you shouldn't be a nurse manager.

[Davey Do]

As a wise supervisor once told me, when I voiced dislike over performing a task,

"Hey- you don't have to like it. You only have to do it".

[amoLucia]

I will speak up on SB's behalf on this topic. It does sometimes gets crazy what nurses start recording on the MARs, which really should only be treatments following physician orders.

But sometimes someone will write an MAR order like "maintain foley cath bag off the floor". Like, duh, this is common nsg practice. It can simply be documented in the pt's care plan! My guess is that someone (?) left a foley bag to drag the floor, so some righteous, noble-minded nurse decided to write an order.

Like what's next --- insure pt is not laying flat-out on floor q shift!?! Insure pt wearing pink ribboned sweater each morning?

Inservice all staff re the foley bag, so if there's another problem, the offending responsible person can be counselled or disciplined as approp. NOT NEC TO WRITE ON MAR!!  Just CARE PLAN IT!

Every now & then, we'd have to clean up the charts of all the minute stuff to the approp site. Otherwise, the whole shift would be truly spent just charting & initialing the whole floor's books.

So I see 4 issues - #1 keeping the writing of pertinent orders to a minimum. #2 Documenting in approp places. #3 Staff inserviced as nec. #4 Individ correction & discipline.

[mmc51264, BSN, MSN, RN]

My pt population has changed so we have pts that have been there for 40, 50, days (as opposed to 3-5). Sometimes there are like 8 orders for VS, etc. We are allowed to delete one-time orders that have been completed. I just recently d/c'd trach care orders on a pt who had been decannulated 2 weeks previous LOL

Removing orders just to avoid charting is bad. Out of scope. 

[JBMmom, MSN, NP]

Yes, this is totally out of scope for nurses and should be addressed. This may be something that is addressed above your level and you should warn people that their license is at risk if they are deleting active orders written by a provider. 

[MunoRN, RN]

Managing the nursing worklist is most definitely within the scope of a nurse, and actually it's the prime role of the nurse.  Nurses who are simply going top-to-bottom of a EMR generated (or generated from any other source) of a worklist are not meeting the basic requirements of a nursing license and should have their licenses revoked.

There certainly are limitations to what can be 'deleted' from the nursing workload, mainly physician medication orders, in which the nurse is within their scope when it comes to refusing to follow the order but cannot discontinue, or "delete" the order all together.

Otherwise though, it's certainly allowed for other independently licensed disciplines to make requests for tasks to be prioritized within a nursing workload, but in the end we are an independently licensed profession that as an expectation of that license is expected to properly prioritize their workload, which more often than not involves "deleting" various tasks requested by different disciplines.  Actually doing their job as nurses, and properly managing a worklist, is clearly not outside the scope of a nurse.

[klone, MSN, RN]

Aren't you the manager? Why are you asking us? If you are unsure how to proceed, a) talk to your manager colleague, or b) talk to your HR rep.

[ComeTogether, LPN]

On 12/8/2021 at 4:12 PM, amoLucia said:

My guess is that someone (?) left a foley bag to drag the floor, so some righteous, noble-minded nurse decided to write an order.

Actually, its done because (usually) there is a history of non compliance and management needs to hold someone accountable.  If its checked off as done, and isn't done the nurse cant say she didn't know, etc. 

Its also done to trigger staff to pay closer attention so more orders like that don't get put in. 

I'm ready to start making the nurses chart the BMs every shift because they don't make sure the CNAs do it......

Never thought I'd be one to defend this total waste of time, but I get it. 

[LibraSunCNM, BSN, MSN, CNM]

On 12/9/2021 at 5:41 AM, klone said:

Aren't you the manager? Why are you asking us? If you are unsure how to proceed, a) talk to your manager colleague, or b) talk to your HR rep.

klone!  I thought we were sticking with "Take care, good luck!" ?