Paper Charting

[bsndeedee]

I know that paper charting has become almost obsolete these days, but I work in extended care at a home care agency. We use a flow sheet for charting and it is all handwritten. I used to put lines in anything that wasn't assessed or needed when charting. There are specific items that are assessed hourly and things that would be charted should something occur in that time frame. Plus there is a nurse note area for abnormal findings. During external audits this has not been an issue but now they want N/A put in every box not used.

I think this makes the flow sheet difficult to read.

Is there specific rules somewhere that says N/A should be used?

I would think if a line can be put through half a page of unused lined paper after a nurses note or doctors note that it would be okay to Pu a line through a box that is not used on a flow sheet.

Another question I have is. When using a flow sheet that covers all aspects of cares, is it necessary to write a full chronological narration of the entire shift?

I have been a nurse for 8 years and I still struggle with writing narratives and would like to decrease the amount that I have to write.

[JWG223]

I've always paper charted. I chart by exception and every two hours. If something unexpected occurs or a procedure takes place I chart it. Otherwise my 2 hour entry may read: 1530hrs vss, no distress.

[Eru Ilúvatar]

I know that paper charting has become almost obsolete these days, but I work in extended care at a home care agency. We use a flow sheet for charting and it is all handwritten. I used to put lines in anything that wasn't assessed or needed when charting. There are specific items that are assessed hourly and things that would be charted should something occur in that time frame. Plus there is a nurse note area for abnormal findings. During external audits this has not been an issue but now they want N/A put in every box not used.

I think this makes the flow sheet difficult to read.

Another question I have is. When using a flow sheet that covers all aspects of cares is it necessary to write a full chronological narration of the entire shift?

I have been a nurse for 8 years and I still struggle with writing narratives and would like to decrease the amount that I have to write.

If I am correct all facilities that deal with Medicare have to implement electronic records this year 2015 or face penalties.

Are there penalties for providers who don’t switch to electronic health records (EHR)? | FAQs | Providers & Professionals | HealthIT.gov

[bsndeedee]

Thank you.

[bsndeedee]

I know that the home care and hospice nurses use ELectronic records and charting but I do extended care in the home and there are very few clients that fall in this category. I spend 10 to 12 hours with these clients and have completely different charting from the other departments.

[bsndeedee]

I thought I would add. The flow sheet has a place for almost everything that I do with a client. Plus I have the paper MAR that shows each treatment and medication. It was my understanding that they developed the flow sheet to decrease the amount of narratives that had to be written. Can't seem to get it through to the managers that we shouldn't have to chart things twice.

[Libby1987]

I do intermittemt visits but our flow sheet type assessment eliminated redundant narrative and when I had a large area not utilized, narrative or column, I would write through it with: N/A------------------------------ initials.

I agree that that a bunch of N/As make it hard to see the numbers at a glance.

[caliotter3]

For extended care shifts, I have had supervisors who have directed field staff to go from one extreme to the other in the narrative portion of the flow sheet. One will require a blow by blow of the shift. Or the shift highlights in a summary. Another will tell the staff that they are not to repeat anything in the narrative that is covered elsewhere on the flowsheet. What is frustrating is when the same supervisor will change up their expectations every few months instead of deciding upon a policy and sticking to it. Otherwise, I just chart the same way that I find useful to me and ride out the winds of change.

[ICURN3020]

I was always taught that nothing should be left blank, as someone could always go back and chart in that open space. Excluding a forensic handwriting/document analysis, it would be difficult to prove who wrote what at what time.

Also, it could be construed that a blank box means the nurse never acknowledged it; by placing a line, you are stating that you did see it but it was not appropriate to chart something at that time.

I'm glad we now use computer charting.

[bsndeedee]

I would love to just use a line instead of N/A what I would like to do is find some guideline that would show that it is acceptable and legal to document that way. As far as I know our policy does not address this specifically. Just a department preference because one nurse charts that way.

[caliotter3]

I draw a diagonal line across the box and write N above it and A below it. On the narrative paragraph, after my last period, I draw a line to the end of that line, place my signature to align with the right side, then place a diagonal line across the rest of the box below that last line. I place my signature on that diagonal line.

[HouTx, BSN, MSN, EdD]

PPs are correct re: rationale & method of 'lining out' unused areas in a paper record.

Hmm - I wonder how long it will be before the word "chart" will be a quaint term that nurses no longer understand. Sort of like kids today when we talk about a "dial tone (annoying noise that tells you your phone connection is working)" or 'LP (large flat vinyl disc with multi-track musical recording)" LOL.