Technical difficulties - not charting

[shannahan]

Long time since I've posted here! Where I work the computer system is having issues and we are unable to chart our regular visits. I was typing up a complete assessment and pasting it into a prn visit narrative section. My supervisor is telling me not to do that. They will not allow paper charting to be scanned in either. We are supposed to hold off on charting until this issue is fixed. I have spoken to IT and they are clueless as to why the system is having issues so I do not foresee this being fixed anytime soon.

My question - what are the legalities of not charting in a timely manner? How long is too long to go without charting? I am not really able to find answers by google searches. Any suggestions on how I should handle this? I am very nervous about going longer than 24 hours without documenting.

[SubSippi]

Thanks everyone for confirming what I suspected. This is a small, newer company and this is not the only issue I've worried about. I emailed the supervisor about the legalities of this and she ended up saying we can type a narrative but when the computer glitch is fixed we will have to go back and enter our charting properly. I've decided to just muddle my way through and complete the charting here and there, however long it takes, to get it done right.

If I were you, I would definitely still keep accurate records. Even if your company doesn't want a copy, save the documents. If anything comes up, you'll need to have yourself covered. If the legal system or BON has to investigate a case for any reason, they won't accept "the charting system was broke" as an excuse.

The days after hurricane Katrina, when people were stuck in the hospital for days without electricity or plumbing, hospital staff was still excepted to keep up with documentation. Many things ended up just being hand written on blank pieces of paper with the date, time, and nurse's signature. Months and years later, when people started to sue, the people who kept up with their charting were very glad they didn't just let it go.

[caliotter3]

There is no way that I would delay my charting. I would do it on a blank form and transcribe it later into the database, but I would never delay it.

[caliotter3]

Agreed you can't just not chart for days on end. What if the patient has to go to the hospital and there are no records available from the PCP? Not good - or at least needlessly exposing the nurses and the practice.

One of my residents went home for the weekend and passed away there. I had a summary due for them and the boss asked me Monday morning if I had done it on time. Thankfully I had. She said it would have been problematic had the documentation been dated for after the death of the resident. Do your charting now on blank paper. You have no way of knowing that one or more of your patients might not die or otherwise have some serious situation happen and you want your charting done.