Overcharting as new grad?

[baby.icu.nurse, ADN, RN]

So I just graduated in Dec and have been working for 1 month in an ICU. My preceptor is absolutely terrible. He hates his life, complains about literally everyone despite me asking him multiple times to stop with the negativity, and he can't ever be wrong. I have proven him wrong on multiple instances and he does not like that very much. Other nurses on the floor have told me to take what he says with a grain of salt. Anyways, what it all boils down to is that he tells me I am overcharting my documentation. He states that he only charts by exception. He also said, and I quote, "If you are charting so thoroughly, it can get you in trouble because when State comes, they will wonder why this new grad is charting so detailed and none of the other nurses are. And usually the one who is over documenting is a new grad nurse who wants to kiss ***." I have seen his charting and he's a terrible documenter. He's gotten mad because I have refused to document his conversations with physicians for him. In addition, my Cerner trainer specifically told us to be as thorough as possible (esp in the ICU) to cover our own asses. I also had an instructor in nursing school who highly recommended against charting by exception as it can hold some of its own legal liabilities. What are your opinions? I've looked for a documentation policy for our ICU and cannot find anything.

[caliotter3]

Unless your supervisor over the unit gives you constructive criticism, take what this malcontent is saying as his attempt to intimidate you into coming down to his level of charting (in)competence. You realize that you doing a good job of charting shows up how little he is doing. Do not chart for him. Keep on, keeping on. Should your charting need some refinement, someone doing a better job than your preceptor will pull you aside.

[Sour Lemon]

I'm not a fan of excessive charting for a few reasons. It's time consuming and can be repetitive, which invites errors ...both in your facts and in your timeline. It can also look bad when a gap occurs in excessive charting, and inevitably, a gap will occur.

I would rather check a box that says the patient was turned every two hours than write out:

20:00 Patient turned to left side.

22:00 Patient turned to right side.

00:00 Patient lying supine.

02:00 Blah Blah Blah.

If I get busy after 02:00, and don't write out the same statement for 04:00 and 06:00 after I've set a precedent, then it looks like I didn't do it.

That's a rather simple sample, but it gets the point across, I hope.

Charting is one of those very personal things, though. Everyone has a different idea of what's too much and not enough.

[JadedCPN, BSN, RN]

I agree with Sour Lemon. I am a fan of box checking and charting by exception for many reasons, mostly because if done properly then it de-clutters all the unnecessarily progress notes so that only pertinent ones remain. Another thing to consider is what your facility policy is. My facility policy is actually to chart by exception.

[baby.icu.nurse, ADN, RN]

Thank you for all of your opinions! We do not actually type out any progress notes or anything. The only time we type is when we need to type conversations, etc that aren't covered by a checkbox. Checking all of the boxes is not time consuming in my opinion. The problem is that for example, there's an order to do a fall risk assessment every 4 hours. He tells me there's no need to do this since "nothing has changed" and that he just does it once a shift even though there's an actual order written by the doctor to do it every 4 hours. I do it as ordered, then he berates me for being excessive and a showoff. ?

[Sour Lemon]

1 hour ago, baby.ICU.nurse said:

Thank you for all of your opinions! We do not actually type out any progress notes or anything. The only time we type is when we need to type conversations, etc that aren't covered by a checkbox. Checking all of the boxes is not time consuming in my opinion. The problem is that for example, there's an order to do a fall risk assessment every 4 hours. He tells me there's no need to do this since "nothing has changed" and that he just does it once a shift even though there's an actual order written by the doctor to do it every 4 hours. I do it as ordered, then he berates me for being excessive and a showoff. ?

A lot of it may be that you're not on your own yet. "Busy work" will be put on the back burner very quickly when you get off orientation.

It's fine to do things your own way, but be open-minded and listen to what your preceptor is saying. Some of it may turn out to be valuable advice, even if the delivery is not squishy-sweet.

As a side note, I hope you're not gossiping about your preceptor with "other nurses on the floor". Assume that absolutely everything you say to any of them will be repeated to your preceptor, because there's a good chance that it will.

[baby.icu.nurse, ADN, RN]

39 minutes ago, Sour Lemon said:

A lot of it may be that you're not on your own yet. "Busy work" will be put on the back burner very quickly when you get off orientation.

It's fine to do things your own way, but be open-minded and listen to what your preceptor is saying. Some of it may turn out to be valuable advice, even if the delivery is not squishy-sweet.

As a side note, I hope you're not gossiping about your preceptor with "other nurses on the floor". Assume that absolutely everything you say to any of them will be repeated to your preceptor, because there's a good chance that it will.

I will take that consideration. I do not partake in gossip as I am well aware of the possible repercussions. It's more like the other nurses approach me because they hear my preceptor talking to me. I just kinda nod my head and say thanks to them. Thanks for taking the time to reply!

[CritterLover, BSN, RN]

A lot of nurses overchart. It is not limited in any way to new grads. Charting according to orders/policy is in no way overcharting. I promise that if regulators see that only a few nurses are charting the required assessments they are certainly going to wonder why that is, but if no one is charting the required assessments they are STILL going to want to know why that is. They look at your policies and know what should be there.

I consider overcharting to be charting your assessment in the flowchart via check boxes, etc and then writing a narrative note summarizing what you just charted in the flowchart. Narrative notes are for covering things that can't be charted in the flowchart (we can't make a checkbox for every possibility).

I usually find it is older nurses who learned "you must write a note every 2 hours" (and the new grads they precept ? ) who tend to overchart.

[caliotter3]

My employers insist, by policy, that we are required to chart something every two hours. I worked hospice continuous care where the requirement changed from an entry once an hour, to every fifteen minutes. Imagine writing every fifteen minutes a novel rendition of the patient is sleeping and breathing. I did not stay with that employer long after they gave the fifteen minute edict.

[RNperdiem, RN]

When you are off orientation, you will figure out what the norms and expectations are for charting in your department. As a nurse you will learn to find the right balance between being thorough in charting where it matters, and time management where you preserve your time for the things that matter.

[KatieMI, BSN, MSN, RN]

From the provider's point of view, overcharting leads to a lot of problems:

- when a nurse writes down 25 notes like "patient repositioned", "patient transported on Xray with...", "patient is sleeping" (at 1, 2, 3, 3:45 and 4:30 AM) and such, it tires the reader up and leads to just skipping most of the notes written by that nurse which can lead to mistakes of judgement;

- overcharting as above inevitably leads to omission of important details. It is quite common to see multiple notes about repositioning while skin assessment stays not performed/not charted for days. Then that pressure ulcer suddenly opens up from nowhere;

- if I see a nurse charting as above, I will have a question if that nurse really does everything else she must do. We all have only limited time; if the nurse spends so much of it charting nonsense, it leads me to thinking that the nurse has poor prioritizing skills and hangs out of the room typing instead of being with the patient, and these thinkings usually come true;

- same as above, overcharting nurses are too prone to overdelegating and overcalling, meaning: they do not access the patient and do not employ critical thinking. A prudent nurse, IMHO, must take vitals herself and know them as well as fresh pertinent assessment data before calling provider instead of stating "oh, it was CENA, I do not know anything else, would you like me to get the CENA?"

- providers tend to remember nurses and what each of them is capable of. Achieving reputation of a nurse known primarily for meaningless charting, endless "updating" and "justlettingyouknow" calls and not knowing the immediate and real situation with her patients is invitation for providers into a "crying wolf" game with a human life in the center of it. It is the same thing as alarms fatigue, and it can end badly for everyone involved. It is a little safer on ICU level as patients there are continuously monitored. Doing that on med/surg floor is directly dangerous. I can write down literally dozens of examples of that.

The fact that someone will get onto you only because you chart more than others is an outright lie. If you do it right, that more likely will save your (and maybe others' as well) back should a legal event happen, but only if you chart right stuff, not random little things. Learning what is important and what is not, and how to deal with that should be one of your top priorities as a starting nurse.

Re. your preceptor, it is okay to get into your manager office and ask to couple you with someone else, or find a nurse or two you can trust and from whom you learn better and use them as underground reserve for learning, not for gossiping and discussing others.

[Subee2, BSN, MSN, CRNA]

For the OP: This is a great question. Charting is an art with a long learning curve and if you always ask yourself , "How could I have done that to be meaningful and sufficient at the same time" ,you will figure this out. Love charting by exception because you have to use you expertise and judgement to make your comments useful to anyone reading this chart .