Time to read the chart, MD notes?

[stellaRN1983]

Hi,

I'm an RN who works the day shift on a busy tele and general medical-surgical floor. A lot of time I get a sketchy report. I get so much more out of reading the MD notes. I don't understand all that is written in the MD notes but get much more info that from the report. It's hard to read the MD notes in morning report because I have 30 minutes to get listen to voice care (recorded report), look at orders, etc. I try to come in early, but we are required to get there by 730 and it's tough to get there earlier with dropping my daughter off daycare. I often feel like I run around and throw medications at my patients and move to the next patient. I feel like I really start to get to know them when I read the chart and take care of them for a few days. Anyone else have this problem?

[tiroka03, LPN]

The thing about getting sketchy report, is you don't know it's sketchy until they have left. You can't say, I know you never give me a good report, so I want to know what your are leaving out or glossing over today. You just get them, and then it hits you. I know who gives me those sketchy reports and will ask multiple questions, and look under and over all the places they sit or can hide things (that you will find later). But, it's usually always the same nurses, you can't find it or prove it was on purpose.

[rkitty198, BSN, RN]

What is Codeine used for in a patient without pain???

Would you hold the drug because the patient isn't in pain as several shifts prior did???

I asked this to the person giving me report and we couldn't figure it out. I practice by not giving anything without knowing the rationale, so in that case I will read the MD notes...

Turns out the patient had short bowel syndrome and it was being given to slow the transit time in the gut so the patient could absorb as many nutrients as possible. The patients electrolytes were off for days and the MD was trying to balance them so the patient could get home. Turns out he didn't know that the staff was holding the codeine because the patient wasn't in pain.

It seems like a waste of time, but I end up with more information which ends up making my patient care better.

[BluegrassRN]

nevermind

[canesdukegirl, BSN, RN]

I agree that Dr's notes have a lot of great detail that can help care for a pt, but $20 says you won't find out whether patient X had bowel movement last night or the smell, color and consistency of said bm in those notes.

I'll see your $20 and throw in another $40 guaranteeing that the on-coming nurse will be able to decipher the BS she will smell if she takes extra time to thoroughly read through a pt's chart.

It is a crime that we as nurses are pushed into time constraints by management because they are terrified of paying for OT. It puts us in a quandry when we want to come in early to review the chart (and NOT clock in because of liability issues), and then cannot stay ON the clock later to catch up on making notes because we *gasp...wanted to read through our pt's chart to get a more clear understanding of how to deliver the best care for them.

I have always read through the majority of my pt's chart prior to delivering care. It is almost impossible to do this while working, so I have to do this the night before. It is different for me in the OR, because I know my assignment for the next day. Most med/surg or floor nurses do not know what their assignment will be, so it is even MORE stressful for our floor peers.

All of us as clinicians feel more prepared if we know our patients. The only way to do this is to have time to review notes. If only we were allowed an hour prior to shift starts to do this (preferably with pay), we would then be better prepared, more organized and have a more clear picture of how to prioritize our day. Wouldn't that be lovely??

[caliotter3]

I have learned fascinating useful information by reading what was available, but the time is never available to do this extra reading.