The Whistle Blower!

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Good morning,

I finally realized in the short time I have been a RN that the computer can be our best friend but it is more of our worst enemy.

I have been thinking about my shift yesterday and because the shift was very crazy, including the very needy and demanding patients, the double and triple documentation (no I am not being dramatic), nurses not wanting to help with drips (there have to be two signatures), the every hour mandated rounding and the unrealistic demands, I failed to document some very important information in the computer. So now I may not have a job but at least I know where I went wrong.

I now know that what is important is that the information is in the computers, even if it is not true. I have been pulled up publicly for missing documentation. You would have thought I commited a crime the way they acted.

I have noticed one nurse not doing her assessments (of course, I would never do this) but I am quite sure that the information on her patients was documented in the computer before she saw the patient.

Oh well, it is the new "whistle blower" and at least it is a lesson learned for me. Does anyone have any thoughts?

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Specializes in Acute Care Cardiac, Education, Prof Practice.

Unfortunately your information is quite vague for me and I am not exactly sure what the situation is/was/will be.

From what I gather you were extremely busy, didn't chart something, someone called you out on it, you are now in trouble, but you believe they are falsifying their own information about their patients?

Not sure what to tell you on that.

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It seems as though it doesn't really matter what kind of charting it is, there is too much of it. Hand written charting is tedious and arthritis provoking and takes up a lot of time, and if you end up charting late, you MIGHT have to do a late entry. Then there are the problems with computer charting like you stated. Seems like the real problem is too much paperwork. (don't we all know that!)

Why not have a toll free number to call where a transcriptionist is on duty and has 5 minutes to transcribe the note that you speak into the phone, which links to your computer system. Kind of like how Drs. do, only immediately, not a few days later? Seems to me this might help the problem and help the economy by all of the sudden there being a need for massive amounts of transcriptionists.

See? If "they" would only ask me, I could solve all the world's problems.:lol2:

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handyRN you are SO right. I just decided that even if it means I am a little late with giving medications that I better do all my information in the computer first. Sounds crazy but I noticed other nurses do the same. At least you can cover your a$$ this way. I don't know. It is just a work in progress. The more unnecessary documentation, the worst it is.

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You are correct.

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I have never thought of the amount of paper work that goes into nursing, but I am not a nurse. I don't know if this is possible or even will help, but there is a program called "Dragon Speak" that allows you to speak your notes and it will type it on the computer for you. I have used it to create essays and it is very handy. I also have heard that Windows has a program like this that is part of the Windows package, but I don't know which version. As one of the previous posters stated, it seems that it would be helpful to just say your notes instead of having to type them.

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Just to give a quick update, I finally spoke with the unit director and I did an excellent job of covering my a**. If I have to work tomorrow, I plan to get the missing documentation completed ASAP. I will also print it out so I have proof of completion.

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Specializes in Med-Surg, Cardiac.

I find that the hardest thing about documentation is finding the appropriate place to put the information and waiting for the computer to respond to the mouse clicks and open the right screen. I remember one place I was at in nursing school. There was basically one screen for charting on a given patient and it had a dropdown where you chose what type of charting it was. Much more efficient than searching through multiple screens.

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Specializes in Med/Surg.
handyRN you are SO right. I just decided that even if it means I am a little late with giving medications that I better do all my information in the computer first. Sounds crazy but I noticed other nurses do the same. At least you can cover your a$$ this way. I don't know. It is just a work in progress. The more unnecessary documentation, the worst it is.

I am wondering what you mean by this....get what information in the computer first? Obviously you can't chart something you didn't do yet, so I think that's where my confusion lies.

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Specializes in PCU/Hospice/Oncology.

It all comes down to ethics. I have actually seen nurses charting assessments that were never done. Ive seen CNAs charting vitals they never took. I got on shift once and found a patient with a stage 3 ulcer.. that had been reported as stage 1 for nearly a WEEK. Not one nurse had looked at the patients sacrum and documented or reported on it.

Im sorry to hear that your unit is not working as a team and that your charting suffered. I heard that for every patient a nurse has over 4, their risk for medication errors increases 7%. Just food for thought for those of you on busy units.

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Specializes in Post Anesthesia.

I've seen some nurses "copy and paste" thier assessments- sounds like a great timesaver but you can end up charting that you extubated your patient every hour for 5-6 hours. That would look pretty silly in a court room.

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