Timely documentation

kat911 · Feb 25, 2006

I have worked with people who always do documentation at end of shift. They do that because they don't give it priority. Things do get missed with this type of work habit. Retraining and consistent expectations from you can help push her in the right direction. It will slow her down initially and will take reminding her to stop and document as she goes. Daily observation and reaffiming your expectations should do the trick. She will have to retrain herself. Good Luck

ABQLNDRN · Feb 25, 2006

I know the importance of Real Time documentation and the impact it has on patient safety. I have a nurse in my department that is always piling up charts and documenting "when she gets time". The content and format of her documentation is very detailed and in all other aspects of nursing she does a great job. I have explained the importance of real time documentation and she states she understands this but she still cant seem to organize her time to achieve this. Any advise on an action plan to help this nurse succeed??

I'd like to tell a little story--I was a nurse intern on an orthopedics unit. On this particular day, I was assigned to work with a R.N. other than my normal preceptor because she was working with a G.N. The nurse (Nurse X) did not document anything right away. The same excuse of not having enough time. Well, one of our patients who had WAY TOO MUCH morphine on board (a whole other story) went into respiratory depression and de-satted to the 60s. (I wasn't in the room at this particular moment). The surgeon flew up to the floor, the unit manager was all over the situation, the charge was in a flutter, etc. Nurse X did not chart ANYTHING. Now, in school they STRESS the importance of timely charting. I asked Nurse X from time to time if she wanted to chart the event. She saying she had more important things to do and would get to it later. So, I went ahead and charted on the patient throughout the day, reflecting with every entry his breathing patterns and O2 sat. At the end of the day, I guess she approached the charge about my charting. The charge pulled me aside and said, "I know you're not supposed to leave lines on the chart, but when something major like that happens, you'll want to leave lines for the R.N. to chart. Otherwise, it looks like she didn't have the time to chart." ????????? SHE DIDN'T! She didn't make time.

I hope that when I'm a full-fledged nurse (graduation 5/06), I always chart right after I'm done in a pt's room. That's what I did as an intern. I had fewer patients, but somehow I was always busy. I have to chart right away. I do not have an impeccable memory, and would hate to caught with my charting pants down in a court of law.

Right before I left the unit, the manager started cracking down on charting. He would, every hour or so, walk around the unit and check charts. Those who were not charting as expected were first given a verbal warning, and if it happened again, were written up.

The bottom line is, when you don't chart right away, you jeopardize your own license and livelihood and ultimately, your patient.