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.

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.

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.

Thank you.

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.

No I have not disclosed it. I have kept it hidden for years and I have attempted to compensate for it. I have only recently discovered through research that My inability to manage time and organize is another part of my disability. I always thought it was my fault and I have not had any medical treatment or therapy since I had corrective surgery to correct my physical defects. Therefore, I am not sure what to do now. I am going to try to talk my family doctor but she is not always receptive. Idon't want to say anything since I have no proof. My childhood record were sealed when my physician died and I am not sure that the hospital that did my assessments and surgery at age 9 would still have any info.

I feel like it is my fault if I am not done. I also have an undisclosed disability that makes me slower than the average person and am not sure what to do about it