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.

[aztec01]

The problem is that nurses notes are no longer viewed the same way as they used to be. Good note-taking protected us legally. Truth be said, very few patient cases ever become litigious and nurses 'notes' are now used primarily by the myriads of certification agencies endlessly parading through hospitals marking off their little check boxes. If our check boxes match their check boxes, we get/stay certified and get paid by Big Brother. That being what it is, I am friends with a recently retired 'expert nurse' who says the decline/lack of charting pretty much guarantees a hefty settlement in court nowadays

[DTWriter]

Doing away with nurses notes is penny-wise, pound-foolish. At one point or another, a nurse will need them, especially when she comes across "that" type of patient:

-the frequent flyer

-the confused

-the dramatic

-the traumatic

-the staff splitter

The list literally goes on.

[catsmeow1972, BSN, RN]

The system my current hospital uses is actually pretty good. We have a decent amount of choices in which to do the click/check box thing, however there is also a place to do a note. Call me old school, but there are things that just cannot be explained by a checkbox. We also have free text places to put "Dr. Smith called for what ever" then when we hear back, "return call from Dr. Smith, received orders.

I like the free text note for things like "pt up in chair, discussed diet advancement, etc." or my favorite "no immediate needs identified, will continue to monitor. I'd like some kind of documentation that I actually went in there and saw the patient.

i need to do at least a short note regardless. Rarely is it necessary to write a book. I know that very very few cases ever see the inside of a courtroom, but is my orifice on the line if it ever does. The majority of the places I've worked would throw a nurse under the bus (and then back up and do it again) if it meant saving themselves a monetary slap or something.

[Nurse SMS, MSN, RN]

We had done away with them and now I am re-educating to bring them back. Too many times something happens and the Epic point and click method does not give a full enough picture. Someone should be able to get into that chart and tell without any doubt what happened on that shift. Avoidance of the nurse note doesn't lend itself to that. HOWEVER..making a note for the sake of making a note is a waste of both the time of the note creator and the subsequent note reader. It should be used only to document instances where it is necessary to give a complete picture of what is going on and that should be at the discretion of the nurse.

[avotoasted]

In most cases, my progress notes are communication for the MD since I work night shift. From what I hear, our MD flowsheets look different from RN flowsheets, so if I have a point that I want to make but isn't terribly urgent, you can bet I'm putting that in a note just to cover my butt.

[Here.I.Stand, BSN, RN]

We're required to write one on every pt, every shift. Now in cases where my shift is over, I'm still charting, and everything pertinent is already documented in the flowsheets? I skip it. I'm not a fan of duplicate documentation. But we all know there are events that DON'T fit into click boxes, and I would flatly refuse to NOT document it at all.

[lindseylpn]

I work in a ID/DD group home and here we still do a lot of writing (paper charts). We do a fully detailed nurses note every 4 hours of our shift.

[chris21sn, BSN, RN]

If it cannot be known through a click, I write it. Better to safe than sorry. I want to clarify what is happening! I need to cover my ass jut in case a law suit walks by, or another nurse decides to throw me under the bus. Even if it can be clarified with a click, sometimes I just write a nurse's note just in case! I really only write a nurse's note if I find there might be a future conflict.

[JordanRose]

And that is downright scary.

[JordanRose]

No way can a series of clicks give you the total picture of what happens during a code, or some other situation. I have dealt with some crazy family situations that needed documented, along with crazy patients. Just being able to "click" everything is a pipe dream.

[ButtaflyRN]

My previous hospital was using EMR since at least 2009 when I was in nursing school, I started working there in 2011 and we were trained to chart by exception, our EMR was rather detailed though. We would of course chart if something happened during the shift, or if a physician was called but that was about it. Enter my new hospital in a new state, nurses notes are loosely expected q2h or at least staff feels that way. These notes on nights are mostly that the pt is resting in bed, respirations even, or if the pt is medicated for pain. I get that that is an exception except I work on a med-surg floor, so not really and the eMar requires you to document the pain level, so it just seems redundant. Now if something happens, injury, change in condition, code, rapid response etc, I will note the event down to the minute to the best of my ability and it will be very detailed but resting in bed eyes closed is too much imo.

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