The charting dilemma

[MattyIrie]

Afternoon CNA's,

i am currently a CNA in LTC and due to other things in my life i end up working PRN at a few different facilities in different parts of New Mexico while in school. One thing i have noticed is the pressure to chart during orientation. now, i see the benefit of being accustomed to a facilities charting procedures and format for CNA's but alot of the time (every time in my experience) the new CNA is left to do the charting alone. I am not comfortable with this for many reasons. the first is that i didnt provide care to all of the patients (residents in LTC) i am asked to chart for. another big reason (predicated on the first) is that i (like most i hope) cannot attach name to face for at least the first week or so which makes it difficult to remember who was who and what was what.

my questions are, have you noticed this as well? and if so, how do you handle this situation?

thanks!

[caliotter3]

Suggest that your nurse give the charting assignment to the CNA who was assigned to those residents. Complete your own charting as soon as possible so that you can get it turned in first, and remind the nurse that your own charting was done in a timely manner. Hold your ground because they will pressure you.

[MedChica]

Sometimes folks will do charting for my pts. For some reason, I don't ask. If there are changes (if they were rambling or disoriented or in pain, etc...), I'll draw a line, make a note or add an entry in the comment section. Then put my initials.

...but, no - I've never done the charts for anyone that I didn't provide care for.

****

Is it something that I notice? Yeah...but, unless a big 'thing' is made of it I'm pretty blase`. Rolls off my shoulders.

****

How have I handled it?

I...just chart for the folks that I cared for.

Now, if told to chart for others? Well...this calls for a little 'passive aggression' on my part.

...because EVEN if told me to do it? I'd still only chart the folks that I personally observed and cared for.

*laugh*

If someone asked, 'Why'?

I'd probably say something, like, "Oh, well - those aren't my residents."

Then I'd pause to ensure understanding, smile and go back to what I was doing.

Now, if the 'someone' continued to press the issue. "O..k. So-oo-oo...."

I'd look up. "Well - yeah...so - I didn't do it because I can't provide details of the care and condition of these individuals if I haven't personally observed them...y'know?"

*shrug*

I mean, really -- what are they gonna say?

"Chart them, anyway...because I said so and if you don't - you're fired?" or "Do it or I'll tell the DON...?"

*laugh*

They know better than that...

That flow sheet is a legal document and I am personally (LEGALLY) responsible for anything that I write.

****

While on orientation, the girls usually considered the residents we did together to be HER residents. Never asked me to chart for her...although, I dind't have much issue doing it. I was observing them, too. Now, she will sometimes chart for me when she relieves me and I'm running overtime - but,

she knows how I am, so...

[cna23]

Do not chart for residents you did not care for. Docters and unit managers will look through it,and you will get caught. Then youll be lying. What if a resident was givin a suppository earlier on in the day, and you put that there were no bm for that day? There is a little simple thing I love called CYA! Cover yours and your license.

[Hygiene Queen]

Do not chart for residents you did not care for. Docters and unit managers will look through it,and you will get caught. Then youll be lying. What if a resident was givin a suppository earlier on in the day, and you put that there were no bm for that day? There is a little simple thing I love called CYA! Cover yours and your license.

Not to be nit-picky... but we don't have a license, we have a certification.

It doesn't matter if your coworkers fall to the floor and pitch a fit. You never put your initials to something you did not do.

If you do, you take responsibility for it... and do you really want to be responsible for someone else's neglect or mistake?

Team work is important and necessary, but it does not apply to charting.

In that instance, you do your own.

[yousoldtheworld]

I do most of the training on my shift at the facility, and this is one thing that I do not do. When it is time to do the charting, I do not leave my trainees alone to do it, and we usually split it - they do the charting for the residents that they did the majority of the work for, or on their first few days, if we did everything together, I have them chart only what they assisted me in doing.

And I agree with others - do not chart anything that you did not personally do, unless you involved enough in the process to vouch for the fact that it got done properly. It happens all the time, and most of the time no one will know the difference - but if you get caught, it can mean serious trouble, as in false documentation.