Overcharting

[greener22, BSN, MSN, RN]

I am not an over charter and I rarely have to stay over at the end of my shift to finish charting. I am actually getting flack from some of my peers because of it. They stay over 1-2 hours every shift finishing triple charting and they are getting in trouble for overtime .They say I make them look bad. I wonder if I am charting enough? I work in PACU where assessments and vitals are taken and charted every 15 minutes. If I give medication between the 15 minutes section, I don't make another assessment because I chart the pain score at say 1500, then the MAR reflects that I gave medication at 1505 , I don't make another assessment at 1505 to state I gave medication and then again at 1515 for the regular time column. Do I need to do that much charting? Is the MAR not enough to show that I did something? Coworkers tell me that every time I do an intervention I have to chart it, but is the MAR not enough? I mean some of them make 60 entries PER hour if titrating drips. Seems ridiculous. What do you think?

[NurseGirl525, ASN, RN]

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?

[loriangel14, RN]

What you are doing sounds reasonable. Yes I think they are overcharting.

[Here.I.Stand, BSN, RN]

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.

[HeySis, BSN, RN]

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.

[Been there,done that, ASN, RN]

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