Overcharting

I only do pain reassessments. Now, if it's say an insulin drip, the glucometer reading is documented. What else do you need to document?

I'm all about working smarter, not harder. And I'm DEFINITELY not about working unnecessary OT. My life outside of work is more important...so heck no, I don't double chart. If they're so concerned about looking bad, they can streamline their charting and get done on time, too.

Besides, I feel like extraneous charting makes the important stuff harder to find. I can't stand looking through the notes on my limited time, trying to get the pt's story (beyond what I was told in report), and having to read through 10,087,799,866,665 one-sentence "narrative" notes.

I work in PACU also, in fact I am orienting and find that each person that I orient with charts a bit different, so today I went to my facilities policies to look at what the minimum requirement is for charting in the PACU pt.

Each unit is different. With ours we are required to do a aldrete every 15 unless there is a change, so If my pt comes to me intubated and gets extubated, then goes onto room air, and it all happens 5 mins apart, I'll have charted three aldrete scores in 15 minutes and then do my next one 15 mins after that if there's been no change. We also have to have one within 10 mins of PACU discharge. So we have baseline for no changes and then are required to document every time something changes.

We also are required to double chart our meds. (once in the MAR and the titrations in the flow sheet, because the MAR only reflects the totals given in PACU not each dose and the times they were given)

Our vitals are every 5 mins for 20 mins then every 10...

I'd check your policy and ask your unit educator or unit manager for what the minimum is and go from there. If you're doing it according to policy then your covered no matter what your co-workers do.

Charting should not be a competition. If management feels your charting is adequate, carry on.