how often do you chart a note and PRIORITIZATION

[direw0lf]

Question 1

Just wondering, how many nursing notes do you make per patient per shift around? My job is 1 note per hour for each patient. We are supposed to document when a physician or other disciplinary is at the bedside, what they order or if there are no orders, etc.

Question 2

I'm having trouble with this. I have 6 patients. I'm giving meds. I'm getting blood sugars and BPs (I'm delegating more to the PCAs when I can. sometimes they are just MIA), I'm calling residents about labs or vitals, the social worker is coming up to me, and you guys know everything else going on.

When I'm giving meds and a patient's family is upset and need me to get their issue straightened out, then 2 other patients have critical labs, meds are all due, I have 6 IV push meds drawn up already and haven't scanned the rest yet, transport just brought back your patient with down syndrome who is hitting staff, the 1:1 is waiting for report, a group of med students are want to know something or other, another patient just went into sinus tach... ok basically ..What do you do when everything just happens at once?

[Nurse Beth, MSN]

My hospital also discourages notes, as reports can't pull free text.

Most likely it's not policy, it's fake news.

Typically, during a survey or following an incident, someone in authority with poor thinking skills declares "From now on, hourly notes must be posted!"

Please check your policy on documentation.

[LM NY]

I skimmed through some of the responses and I completely agree that it is a waste of time. If there is a change in the patient’s status, I will document the change as well as the intervention blah blah blah. What I do notice is when my patients come from the ED, the ED nurse documents random things like “family at the bedside” or “doctor drawing labs”. I’ve always wanted to ask an ED nurse in my hospital, but keep forgetting.

[Nickc58]

The policy for our nurses includes a couple templates that need to be filled out (I+O, body systems, vte risk, IV assessment, teaching, etc). Besides these we only chart “clinical notes” if someone of importance happened. “Got patient oob for first time without nasal cannula. Ambulated to nurses station and back. Gait weak but steady, o2 sat remained around 95.” Something like that

[Nickc58]

Just now, LM NY said:

I skimmed through some of the responses and I completely agree that it is a waste of time. If there is a change in the patient’s status, I will document the change as well as the intervention blah blah blah. What I do notice is when my patient’s come from the ED, the ED nurse documents random things like “family at the bedside” or “doctor drawing labs”. I’ve always wanted to ask an ED nurse in my hospital, but keep forgetting.

I know this one ED nurse who writes a note EVERY SINGLE TIME SHE WALKS INTO THE ROOM. I think this is as thorough as one can get. She does it instantly after her encounter with the patient, basically in the door way.

[Ruby Vee, BSN]

On 4/3/2019 at 10:11 PM, direw0lf said:

Question 1

Just wondering, how many nursing notes do you make per patient per shift around? My job is 1 note per hour for each patient. We are supposed to document when a physician or other disciplinary is at the bedside, what they order or if there are no orders, etc.

Question 2

I'm having trouble with this. I have 6 patients. I'm giving meds. I'm getting blood sugars and BPs (I'm delegating more to the PCAs when I can. sometimes they are just MIA), I'm calling residents about labs or vitals, the social worker is coming up to me, and you guys know everything else going on.

When I'm giving meds and a patient's family is upset and need me to get their issue straightened out, then 2 other patients have critical labs, meds are all due, I have 6 IV push meds drawn up already and haven't scanned the rest yet, transport just brought back your patient with down syndrome who is hitting staff, the 1:1 is waiting for report, a group of med students are want to know something or other, another patient just went into sinus tach... ok basically ..What do you do when everything just happens at once?

Whoa! That's a lot of charting. Even with just 1-2 in the ICU, I don't write notes that often. I'm in a large teaching hospital (over 1100 beds), and there are many different disciplines visiting. I've gotten so I just put a quick comment on the VS page rather than writing an entire note. ("Renal service at bedside." or "PT with patient."). Besides, THEY are supposed to be writing a note about what they did and said and concluded. If they don't enter orders, then there are no orders. I cannot imagine keeping up on 6 patients and writing a note every hour!

[Party_of_five, BSN]

On 4/7/2019 at 2:08 PM, LM NY said:

I skimmed through some of the responses and I completely agree that it is a waste of time. If there is a change in the patient’s status, I will document the change as well as the intervention blah blah blah. What I do notice is when my patients come from the ED, the ED nurse documents random things like “family at the bedside” or “doctor drawing labs”. I’ve always wanted to ask an ED nurse in my hospital, but keep forgetting.

We do that because often pts are taken care of by several different nurses. Our reports to each other are very brief and/or nonexistent. The lab part is helpful when you see that labs were sent 30min ago but do not show in process. So then you could call the lab and find out what happened.