Nurses Notes - A Thing of the Past?

[Smb411]

Are nurse notes becoming a thing of the past? My hospital has just informed all nursing staff that we should not be writing any nurse narrative notes. All charting should come from "clicks" in our new documentation program. The reason they gave was that notes do not cross over the same way as documenting in the clicks. Anyone out there not writing any notes in a 12 hour shift? Almost seems impossible to me.

[JKL33]

Right. It doesn't work well for data collection. Here's my take: There's a lot that can be charted by clicking boxes. And there are a lot of nursing notes that don't need to be written. But if there is a situation that just doesn't lend itself to documenting by picking from a list, I will be making a note. Long before we became data entry clerks, it was widely known that the medical record is a legal record of care provided, as well as someone's record of their healthcare and health conditions. Those two things are a pretty big deal as far as I'm concerned.

I've been in places where we were encouraged to minimize the use of narrative notes, but I've never been told outright that we couldn't; and I'd probably be a voice of dissension if that happened. There's usually an option to right click and add a very brief note or clarification, and usually that's all that is needed. No need to write a book.

[Sour Lemon]

Are nurse notes becoming a thing of the past? My hospital has just informed all nursing staff that we should not be writing any nurse narrative notes. All charting should come from "clicks" in our new documentation program. The reason they gave was that notes do not cross over the same way as documenting in the clicks. Anyone out there not writing any notes in a 12 hour shift? Almost seems impossible to me.

I only write them for about half my patients, and I only write what I cannot document with "clicks". There's too much risk of conflicting (assessment does change throughout a shift) and when everything matches, it's just useless busy work.

[vanilla bean]

That would be AWESOME! **insert unicorn pooping rainbows here**

I am required to write a note on all my patients. Every shift. Regardless of whether it merely duplicates all of my box checking or not (it does). Regardless of whether it is a waste of my time and busy work (it is).

I am now dreamy with the idea of only writing a note if something is not adequately explained or described by my thousands of clicks of documentation during my shift.

[caliotter3]

I just loved it when a hospice agency changed the requirement to charting a narrative note every 15 minutes for an otherwise sleeping hospice patient. Any patient who is peacefully sleeping poses a challenge to create a unique chart entry every 15 minutes.

[kaylee.]

This is a good topic and would love to see what others' views are. I am not a fan of the "patient safe, nothing happened" note.

When something happens I write an accout of the situation...And when nothing happens I find i am sitting there thinking of something to say. Its feels like busywork.

And the EPIC ppl have said not to do it. But this was said once at a tutorial.

Since management has not said anything on it either way, I still question whether or not:

A) a normal shift note is expected, and B) a normal shift note is actually a good idea.

It just seems like it could open the nurse for liability legally when nothing more should be added.

[missmollie, ADN, BSN, RN]

You call a doctor and they dismiss your concern. You bet your bottom dollar I'm charting that, with quotes, and verbatim what the doctor said to me. Clicks or not, I will not be thrown under a bus because we should just choose boxes.

Legally, the place you work for cannot change your nursing notes, so you protect you.

[AceOfHearts<3]

You call a doctor and they dismiss your concern. You bet your bottom dollar I'm charting that, with quotes, and verbatim what the doctor said to me. Clicks or not, I will not be thrown under a bus because we should just choose boxes.

Legally, the place you work for cannot change your nursing notes, so you protect you.

Nailed it. You bet I am charting that "Dr. ABC was notified of XYZ. No new orders at this time." I am covering my hiney!

[JKL33]

Agree. Sometimes conversations with people, not just physicians, are important to include. Tons of situations/examples of this.

And I'm also thinking of situations where the way the assessment was built into the program just doesn't even lend itself to documenting some of the more common findings. Or it must be done in a laborious fashion by visiting 4 the sections just to chart a simple thing, like open fracture for example. We have a number of items that are well known findings that, when you go to that system/area to chart it, there aren't relevant/accurate options to describe your assessment. I won't click boxes that don't convey my findings just to meet the box-clicking requirement.

[retiredmednurse]

I agree with JKL33 above. When our hospital went to the e-charting, including assessments, we had 6 nurses in the IT dept. All we had to do was make a comment of what we wanted to see added or clarified, and it was done. One example I had clarified was "hematuria". I wanted grades of hematuria. The range from light pink, salmon-colored, to bright red like a cherry popsickle melted, to frank blood. This they did so I wouldn't have to make a comment. I always wanted to 'paint a picture' of what I saw in case I was ever called to court. Of course, if there were strings or clots, then I did make a comment.

[BSN16]

I didn't realize how much of a fan i was of nurse notes until i went to a facility without them. Yes, it was frustrating when nothing happened during the shift, so some generic note like "patient is resting in bed comfortably, no concerns at this time."

However, i have found that getting a definitive timeline for a patient is hard to come by from just provider notes alone. At my new job, when looking up a patient, i often wonder "When was this patient extubated, why were they intubated, when was like line put in...etc"

Usually it's nice because nurse notes are generally straight to the point

example: 7/3 Pt brought up as RRT for SOB and increase o2 demanded. intubated at 1600.

7/4: patient BP 80/40. Levophed started. Artline inserted for closer observation.

etc..

[malamud69, BSN, RN]

Less is more