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how often do you chart a note and PRIORITIZATION

Nurses   (1,987 Views | 17 Replies)

direw0lf has <1 years experience as a BSN.

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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?

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Sour Lemon has 9 years experience.

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1. I usually write one note (per 12 hour shift) explaining anything that doesn't exist elsewhere in my charting. Complex or difficult patients might get several notes. Stable patients with no significant changes might not get a note, at all.

2. I prioritize and reprioritize with each new situation or task that occurs.
I also present myself as exceptionally helpful during initial rounds so that patients and families are more likely to be tolerant when there are delays. They know that I want to be there and they know that I will come as soon as I possibly can when they need me.

Edited by Sour Lemon

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Here.I.Stand has 16 years experience as a BSN, RN and specializes in SICU, trauma, neuro.

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That’s ridiculous.  Other disciplines should be doing their own charting — that’s not nursing’s job.  Also orders: they input their orders, so unless you are discussing your nursing observations after implementing them?  It makes no sense to write in the notes what they ordered.  

I’m in an ICU and we have to chart a full assessment every four hours; we chart VS at minimum q1 hour, hourly rounding, and any frequent focused assessments.  I usually write a shift summary in narrative form, and anything that can’t be easily ascertained from other charting.

 I avoid double documentation as much as possible— it’s just not a good use of my nursing time.

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13 Followers; 4,056 Posts; 31,261 Profile Views

10 hours ago, direw0lf said:

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.

Writing down that someone else came to the bedside and then left again and whether or not they ordered anything is a ridiculous waste of nursing resources. Likewise for hourly notes that don't say anything. Also no small matter: You can create problems with all of this that otherwise wouldn't exist. There is potential for inconsistency here and also potential for creating apparent contradictions where none exist.

It sounds like your place is pretty much behind the times.

I think you should look into whether there is a different/better capability within your EMR for documenting that hourly rounding has been completed. And then advocate for the rest of this to go away.

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Here.I.Stand has 16 years experience as a BSN, RN and specializes in SICU, trauma, neuro.

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Another thought about hourly notes:  sometimes I want/need to read interdisciplinary notes for learning about my patient.  It sounds like a behemoth pain in the butt to scroll through 24 nursing notes to get to the case manager’s note or the SLP’s findings.  

I can’t imagine the physicians like it either when looking at consult’s notes... or RELEVANT nursing notes.  The other day I identified some signs of PTSD in an assault victim, and noted she hadn’t had a psych consult.  The next morning the team knew about it before I had a chance to ask for the consult.  

But something like “Pt watching TV and eating green jello.  Requesting red jello.  Will continue to monitor”.... or “Pt is on the bedpan.  Denies pain.  Will continue to monitor,” or “Pt eating turkey sandwich.  States he looooooooves our turkey sandwiches.  Will continue to monitor.”  🙄😒

What a stupid requirement.   

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FolksBtrippin is a BSN, RN and specializes in Psychiatry, Pediatrics, Public Health.

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I can't imagine why you'd need an hourly narrative note. Or even how that could be possible. Maybe a checkbox. But even that seems unnecessary. Hourly rounding is great if you can do it. I would imagine that it is not always possible. That's why you have call lights. 

I don't work in the hospital anymore, but when I did,  we had to chart one assessment per shift. We charted significant changes when they occurred. These would go in a narrative note if they were outside our checkbox style flowsheet. I did not then and still do not double chart.

As far as prioritization, prioritize like a nurse. NCLEX taught you that. Your patients come first.  You need to chart for the purpose of communicating to other people taking care of your patient. Don't chart what other disciplines do, chart what you do. Chart information that matters.  "Patient eating turkey sandwich" probably isn't relevant. But if your patient was psychotic and believed the hospital food was poison last shift, then it is. 

Right now I work with some social workers whose notes I  never bother to read because they are full of extraneous information that has no value whatsoever. Don't be that person if you can help it. 

 

 

 

 

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Swellz has 6 years experience and specializes in oncology, MS/tele/stepdown.

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Is this an actual policy? If there is no policy saying you need to do that, I would stop. That's insane, a waste of time, and impossible to do with 6 patients.

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1,192 Posts; 8,019 Profile Views

I rarely type notes at all.  It should be in my assessment.  Will control monitor is one of the stupidest nursing phrases out there.  

I type notes if something happened that I need documented that is not on my assessment.  

Are you sure you understanding correctly that you need an hourly narrative note on 6 patients?  Who is going to read that bunch of nonsense?

We have so much charting to do already.  I’m not adding additional notes on things I’ve clicked boxes for.

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Matthew RN has 13 years experience as a MSN.

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1) Our hospital discourages notes.  Notes only for something that nurse feels is ultra important that can't be charted any other way.

2) When everything happens at once ask the charge nurse for help.  Their responsibility is to help all the nurses on the floor.

 

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85 Posts; 989 Profile Views

I document progress notes once per shift for my patients 🙂 
Even as a student on prac in ICU where observations etc were documented as a minimum once an hour we only wrote progress notes once per shift. 
The only circumstances where I have documented more frequently is Labour & delivery where we documented at least once every half an hour.
The only times I document about other members of the multi-disciplinary team is when I have made a referral/escalated something to them - It is their job to document/record what they have or hasn't done for the patient

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HelloWish has 3 years experience as a ADN, BSN and specializes in IMCU, Oncology.

486 Posts; 7,239 Profile Views

I do not chart every single hour, and I work in critical care in a step down unit. If I find I need to frequently chart in narrative, I addend my progress note and add to it with the times. I narrative chart frequently for cases of attempted suicide or something really serious that needs frequent documentation. Otherwise I write one progress note with the important information at the end of shift. For instance if it is a patient with a leg hematoma or DVT or something of the sort and I am watching for compartment syndrome, I chart left/right leg pulses and sensation intact throughout shift. I only chart pertinent info that is helpful for another person to read or to remind myself later on. 

I agree about charting about notification of the physician for critical labs, important findings etc. as it does protect you.

Edited by HelloWish

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420 Posts; 2,013 Profile Views

I'd like to know what your write for those hourly notes.  And agreed, you shouldn't have to chart when doctors, SW etc visit the patient.  That's for them to do.  

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