It's probably been said more than once, but I wanted to get my thoughts out while I still know what I want to say on this topic.
Sure, I've read the chart if you give me more than 5 seconds between the admit being paged, and you calling to see if I've looked at the chart.
I've also read what precious little has been charted there. Half the time, the ER has put in a Foley and not charted it. I've seen more IV's started and not charted. So...is that a field start I need to take out and re-start? Or did you start that in the ER? Also, I can't get a good picture of what's going on with this patient if the physician/practitioner hasn't actually written a note. 3/4 of the time at my facility, that hasn't happened yet. And yes, I see that you put in 7 nursing notes about this chart. "Pt transported to CT." "Pt returned from CT." "Up to commode." Those are not as helpful as you might think. I need an idea of WHY this pt is here. It's also helpful to know WHY meds were given. You gave 80 of Lasix? Great! Why? If there aren't any notes for me to read, I can only make an educated guess.
So yeah, when the charting is not great, I'm probably going to ask you a few questions. Please don't bite my head off. I really want to do the best I can for this patient, but if I don't know anything about them ahead of time, it's hard for me to know what to have at the bedside, and what other things I might expect over the course of a shift. See, that's the difference between ER nursing and inpatient nursing. We're pretty much stuck with our patients for the whole shift. You get them for a little while and either send them home, or send them to me.
I realize the tone of this might not come across very well, and that's not the way I intend it. ER nurses work very hard at what they do, and they're very busy. I get that. I'm busy too. But what really cheeses me off is when I'm expected to read minds. Or non-existent charting.
