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Technical difficulties - not charting

Nurses   (2,291 Views | 14 Replies)

4,503 Profile Views; 239 Posts

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.

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classicdame is a MSN, EdD and specializes in Hospital Education Coordinator.

2 Articles; 7,255 Posts; 27,196 Profile Views

not a good decision in my opinion. Our BON expects timely charting. It assists in continuity of care. If that happened at my hospital our policy is to revert to paper charting for the interim.

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VANurse2010 has 6 years experience.

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not a good decision in my opinion. Our BON expects timely charting. It assists in continuity of care. If that happened at my hospital our policy is to revert to paper charting for the interim.

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.

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classicdame is a MSN, EdD and specializes in Hospital Education Coordinator.

2 Articles; 7,255 Posts; 27,196 Profile Views

In my facility, failure to chart on time means the risk manager must be notified. Charting long after an event gives one the opportunity to make things up. Lawyers like that.

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239 Posts; 4,503 Profile Views

I am so worried about this. I've tried to find the rules/regs on the Arizona BON to show my supervisor but am unable to locate it.

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classicdame is a MSN, EdD and specializes in Hospital Education Coordinator.

2 Articles; 7,255 Posts; 27,196 Profile Views

I do not live in Arizona but looked up the NPA on the BON website. Look at Rule P4-19-402. Print it out and take it to your supervisor or the risk manager and ask how you are expected to abide by this rule. No need to be confrontational. Just ask their opinion. I personally believe you will be held responsible if you cannot document what has gone on with your patients. But try to get the facilty to be on your side.

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Pepper The Cat has 34 years experience as a BSN, RN and specializes in Gerontology.

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There must be some sort of down time procedure to follow. Can you look for this?

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dudette10 has 9 years experience as a MSN, RN and specializes in Med/Surg, Academics.

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There must be some sort of down time procedure to follow. Can you look for this?

This. Your employer could be in very hot water if you are all told to just wait until the system is fixed.

In my opinion, your "fix" that the manager who inexplicably told you to stop doing was a good one.

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amoLucia specializes in LTC.

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It's sounds like a risky issue to me, too. If you have your own malpractice insurance, you might want to check with them. I think they would find it problematic also. They could provide you with the ammunition you need to alert your hospital's risk management/legal dept.

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MunoRN has 10 years experience as a RN and specializes in Critical Care.

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I would pass on what your employer told you to the department of health, let the DOH and your employer hash it out.

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Altra is a BSN, RN and specializes in Emergency & Trauma/Adult ICU.

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From a regulatory standpoint, downtime procedures are considered to be part of an adequate emergency preparedness plan. If no documentation is done for days ... there could be hell to pay the next time the organization goes through a site visit.

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239 Posts; 4,503 Profile Views

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.

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