Patient Care vs. Documentation Requirements

[whitescrubsgirl09]

I have been working in a hospital for a few weeks now, and I have found it difficult to balance patient care and meeting the documentation requirements. I spend 5 minutes helping a patient and 10 minutes documenting what I did. How do I find a balance?

[smitty10]

i think it is the same way you get to Carneige Hall :) Practice, practice practice!!!!!

[phlox]

Sadly, with so many lawsuits, one has to document every little thing, so you simply must learn how to care for your patient and be a whiz at charting too. Eventually, it becomes second nature. Some facilities have better flow sheets to chart on than others and now and then nurses can make suggestions on how the charting can be improved to make sure no detail is skipped and all bases are covered in the least amount of time. Patient care should be the priority, but often is not.

[RNperdiem, RN]

Sometimes I have to force myself to sit down and chart the assessments right after they are done. The computer charting takes twice as long as the actual asessment performed.

Nurses vary in their preferences. Some, like me, like to chart as they go, and others like to do a lot of patient care and then do a lot of catch-up charting later.

[ayla2004, ASN, RN]

the neverr ending strugle give care and dociment care given and get out on time.

i know that my narrative notes suffer when im pressed for time and i worry they wont be sufficent.

[PostOpPrincess, BSN, RN]

In my department, no matter how well you take care of your patient, if you don't document it--you didn't do it as "well" as you think.

You may have assisted in giving your patient an excellent hospital experience, but you didn't note it--it didn't happen.

[shbryer]

Well, it has to be done, but when you have time. Make time for the patient first. Stay late if needed to chart