I have been a nurse for 17 years. I have worked both med/surg and ICU in a CAH (critical access hospital) my whole career. For the most part, I have really enjoyed my job. The past few months though, I find myself becoming more dissatisfied with my job. I still enjoy taking care of patients. It is the relentless, mind boggling, idiotic, double and triple charting that I am starting to despise. The charting is starting to really cut into my direct patient care time. I am a very organized, usually have all my ducks in a row. I can get my first assessment done, my meds passed, update the rounding doctor on the pt's condition, review the orders, and sit down to chart in a reasonable amount of time. (Our charting is computerized). I just can't seem to keep up anymore.
For example, now it isn't good enough that we chart "NKA" on a chart. We have to chart "NKDA", No Known Food Allergies, No known environmental allergies. We have to chart pain assessment every 2 hours, around the clock. If a catheter is in longer than 2 days, we have to document why the catheter is still in place. All kinds of new documentation requirements for vents and central lines. Flu/pneumovax vaccine sheet needs completed. Valuables sheet completed. Med Reconciliation form filled out on the computer. Pt receiving blood or blood products? That form needs completed. New admission? Then you get to start a whole new slew of paperwork/computer work. Oh, let's not forget the DVT prophylaxis order form. The list goes on, and on, and on, and on. It keeps getting longer too.
When will TPTB (on all levels...hospital administration, Joint Commission, state board of healths, insurance company, etc) realize that nurses are getting frustrated with all the forms and assessments we have to fill out with each pt? Even a 40 year old pt in with an uncomplicated case of pneumonia, the documentation is unreal anymore.
I don't see this easing up at all for bedside nurses. I am in my mid 40s with an ASN degree. I am seriously consider starting back to college to obtain my BSN, and possibly my MSN so I will have more job opportunities available to me other than bedside nursing. I am even considering leaving nursing all together. Not sure what area in would venture into though. Definitely have to think that one through.
I know good nurses are being driven away from the bedside because of various reasons. My sore point with nursing @ the moment is the excessive charting and documentation that is required of us.
Sounds like you need to find a new place to work...
If I have a max of 3 patients, it takes ~7 minutes computer charting x 3 patients x 4 assessments = 84 minutes plus ~15 minutes for miscellaneous things like progress notes, so all in all a little more than 1.5 hours out of my 12 hour shift max, usually much less because I generally only have 2 patients and some of those with only 3 assessments needed...
Specializes in Tele, Med/Surg, Case Mgmt, Ins. Rev.
I left hospital nursing out of frustration of being pulled from the bedside with all of the bright ideas everyone came up with.
Additional forms, more frequent computer charting, with computers only at the desk available, nothing near the patient rooms. Add to that the new medication dispensing system (6 nurses getting meds for 6 patients each, all due at 0900), a system that will only allow you to pull your meds in a 30 minute window of time to be given to prevent med errors, otherwise it will not allow you to dispense without an override by pharmacy. But wait, there were still errors, so they added to that a little hand scanner with additional documentation that you had to use to scan the patient, scan the mar, and scan the med before dispensing each med after you stood in line to get the med out of the machine..... but had to get everything done within the 30 minute window or you had a med error to address.
Updated skin forms q shift, med rec q shift, updated report and med rec done every time the patient left the floor for testing or procedures and repeat upon the patients return. Review the Care Plan at the beginning of the shift, and at the end of the shift as something may have changed. Q 2 hour pain assesments, q 1 hour repositioning, hourly nurses note entries. Add to that report to the charge nurse at the beginning of shift, report to the nurse manager when she arrived, discuss with the nurse manager her findings after she did quality rounds with each patient (Ms. Jones in 12 is upset she hasn't had her icewater refreshed in 2 hours) Admits, discharges, transfers in and out and all of the paper work associated with. Wound care, foley care, NG care, trach care, assist Docs with rounds, review reports, call Docs..... and remember, no overtime allowed!
How can you effectively teach patients about their illnesses, treatments, tests and meds? How can you assist with AM care so that you get a complete look at their skin. How do you fit in the time to hold their hands and LISTEN to your patients?
Administration needs to comprehend what their nurses do, experience several shifts, prior to adding, adding, adding while taking away staff..........
It got really bad when we would get a "pop-up" on our computer screen if pts showed S/S of "possible" complications that we'd have to immediately address with the doc. ie: a 94 yo pt with elevated BNP (pop-up- possible CHF) call doc, who did NOT want to be woken up for this news (of course she has an elevated BNP, she's 94!) but we HAD to call. Same for S/S of sepsis (really? Elevated WBCs with a pna pt???? Call doc, get yelled at, and document, document, document).
The above is so infuriating! What ever happened to looking at our patients and not just what lab values or machines say? Of course I don't ignore any of the above, but it the pt isn't showing ANY s/s of acute distress related to what the damn computer is 'prompting', I don't want to be waking up doctors! They can see them on their rounds in the morning unless they become unstable in the meantime. I can see it now "Dr, pt BNP a bit elevated. No she's not SOB, sats are fine, BP wnl, nope no wet breathing, no cough, minimal edema consistent with baseline. She really is asymptomatic, but I have to call the computer told me to".
I have been doing this for 39 years and things never get better. We, on med/surg/tele unit, audit all charts nightly to see if all the extra papers are being completed on top of all the senseless charting. It must be done and can be no over-time. Pt/nurse ratio on nights ate 7:1. We average 5-9 admissions a night. I am counting the yrs to retirement (which may be on my hover round scooter) It seems patient care comes second to paper work anymore.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Sounds like you need to find a new place to work...
If I have a max of 3 patients, it takes ~7 minutes computer charting x 3 patients x 4 assessments = 84 minutes plus ~15 minutes for miscellaneous things like progress notes, so all in all a little more than 1.5 hours out of my 12 hour shift max, usually much less because I generally only have 2 patients and some of those with only 3 assessments needed...
Don't leave the NICU......it's a big bad world put there....:hug:
Sorry, but the comment about skin care sheets saying "no breakdown", then you find out your patient DOES have debub(s)!! There is NO excuse for that! Yes, I HATE all the paperwork, too, but if people are charting NO BREAKDOWN, that is totally unacceptable! We HAVE to assess the patient, no matter what! I have had tha happen too many times, also! Since when do nurses think it's okay to LIE about an assessment!!?? If you honestly did NOT look at their sacrum/ heels, etc.....just ADMIT it! Do NOT tell me they have no breakdown, then I go to assess them and I see a horrible stage THREE!!?? And just recently, I had a patient who had sadly gone from a 2 to a BAD 3....yet people continued to chart "stage 2..." SERIOUSLY??? That's just horrible!!! I felt so bad for that sweet patient!!
Sorry, but the comment about skin care sheets saying "no breakdown", then you find out your patient DOES have debub(s)!! There is NO excuse for that! Yes, I HATE all the paperwork, too, but if people are charting NO BREAKDOWN, that is totally unacceptable! We HAVE to assess the patient, no matter what! I have had tha happen too many times, also! Since when do nurses think it's okay to LIE about an assessment!!?? If you honestly did NOT look at their sacrum/ heels, etc.....just ADMIT it! Do NOT tell me they have no breakdown, then I go to assess them and I see a horrible stage THREE!!?? And just recently, I had a patient who had sadly gone from a 2 to a BAD 3....yet people continued to chart "stage 2..." SERIOUSLY??? That's just horrible!!! I felt so bad for that sweet patient!!
Perhaps if nurses weren't so busy with all the required paperwork, they'd have time to assess their patients. Just a thought.
I gotta say, I've been on the floor and a manager and managers are not exempt from having to comply with the endless regulations and governmental hoops. Seriously. Being a nurse exec means - documenting.
Sounds like you need to find a new place to work...
If I have a max of 3 patients, it takes ~7 minutes computer charting x 3 patients x 4 assessments = 84 minutes plus ~15 minutes for miscellaneous things like progress notes, so all in all a little more than 1.5 hours out of my 12 hour shift max, usually much less because I generally only have 2 patients and some of those with only 3 assessments needed...
Not sure what kind of unit you work in, but I work in an ICU. Our policy requires that pt's be charted on q 2 hours; full assessments q4 hours. Our computerized flow sheet is long (CPSI...not sure if anyone here is familiar with that computer charting. If I have 2 patients, it can take an hour to chart both of them correctly for the full assessments. This doesn't include tracking down labs and other tests, accompanying patients to radiology and back. We have no CNAs in our unit; we do full care. That means we feed them if they are not able to feed themselves, no unit clerk, just be and one another RN. Can get quite hectic at times. Not to mention if we get one unstable patient, or one crazy family and that can add to the load and the charting.
I feel like I am taking care of the chart more than I am taking care of the patient.
Not sure what kind of unit you work in, but I work in an ICU. Our policy requires that pt's be charted on q 2 hours; full assessments q4 hours. Our computerized flow sheet is long (CPSI...not sure if anyone here is familiar with that computer charting. If I have 2 patients, it can take an hour to chart both of them correctly for the full assessments. This doesn't include tracking down labs and other tests, accompanying patients to radiology and back. We have no CNAs in our unit; we do full care. That means we feed them if they are not able to feed themselves, no unit clerk, just be and one another RN. Can get quite hectic at times. Not to mention if we get one unstable patient, or one crazy family and that can add to the load and the charting.
I feel like I am taking care of the chart more than I am taking care of the patient.
I work in a NICU (level 3 with post-ops, HFOV, ECMO, etc along with some feeder growers) and we do hourly vital signs as well, but it's just a click of the mouse because they auto-populate from the monitor (as do the I&Os, hourly IV assessments, although we do have to manually click "assessed"). We have a few techs for when we have 3:1 (stable babies), but generally I do all the care, especially since babies are total care, although admittedly they generally weigh
Calling lab and doing field trips to the OR/fluoro/cath lab/MRI isn't something that I really consider to be documentation, but yeah it can eat up a bit of your time. I most often call pharmacy to ask politely where my stat meds are.
I know that adult care can be a bear, especially if they're total care. I
I can't believe you spend so much time charting! Seems very inefficient.
but yep, I'm never leaving the NICU. I would probably quit nursing if I had to do adults or even peds. Kids are another bear I don't want anything to do with!
I work in a NICU (level 3 with post-ops, HFOV, ECMO, etc along with some feeder growers) and we do hourly vital signs as well, but it's just a click of the mouse because they auto-populate from the monitor (as do the I&Os, hourly IV assessments, although we do have to manually click "assessed"). We have a few techs for when we have 3:1 (stable babies), but generally I do all the care, especially since babies are total care, although admittedly they generally weigh
Calling lab and doing field trips to the OR/fluoro/cath lab/MRI isn't something that I really consider to be documentation, but yeah it can eat up a bit of your time. I most often call pharmacy to ask politely where my stat meds are.
I know that adult care can be a bear, especially if they're total care. I
I can't believe you spend so much time charting! Seems very inefficient.
but yep, I'm never leaving the NICU. I would probably quit nursing if I had to do adults or even peds. Kids are another bear I don't want anything to do with!
I always chart "pt to radiology accompanied by RN and rad tech, blah, blah, blah." I chart when the return too. If they went with O2, monitor, bed, cot, etc. Just another way to cover my butt. A lot of our stuff doesn't auto populate, which means we have to enter it manually. I don't think CPSI is the most user friendly computer charting system out there either. But regardless of the computer charting system we would have, it still wouldn't change all the stuff they want documented now.
And if I hear the words "meaningful use" one more time, I may have to throw a chart at someone. Another word created by our wonderful federal government on how to provide healthcare. New rules and guidelines being made by people who wouldn't know the difference between an emesis basin and a bedpan!
You can thank Medicare for some of the charting. Medicare will NOT reimburse a facility for any nosocomial UTIs. Period. If a patient gets a UTI, and because they're train wrecks to begin with, end up with sepsis and 3 weeks of otherwise unneeded hospitalization, the hospital has to eat the bill.
Skin issues are partly due to LTC transfers. If a patent is sent to an LTC with any decubs, the LTC doesn't get dinged, and it reflects back on the hospital. Even a simple skin tear or blister (I got one from foam tape s/p PICC placement on 4-1-11....still hasn't healed), that uses Mepilex- which is great stuff, but 6 bucks for a 2x2 dressing.
Pain assessments were a pet project of JCAHO a while back- don't know if they're still the driving force behind those.
Another thought, how do you document if you don't assess?
I'm wondering how much of the "customer service" issues are a big reason for having time issues with charting. It's hard to get paperwork done with the whole concierge attitude that is encouraged by the suits. :two cents:
babyNP., APRN
1,923 Posts
Sounds like you need to find a new place to work...
If I have a max of 3 patients, it takes ~7 minutes computer charting x 3 patients x 4 assessments = 84 minutes plus ~15 minutes for miscellaneous things like progress notes, so all in all a little more than 1.5 hours out of my 12 hour shift max, usually much less because I generally only have 2 patients and some of those with only 3 assessments needed...