Unprofessional charting

[Nurse131382]

I work on a busy cardiac floor and most of our PCT's don't make hourly observations in the EHR. However we have one who does and it is riddled with spelling and grammar errors. It also doesn't include what I perceive as important information that needs to be charted. For example "patient sitting in chair eating a piece of candy, does not like what is on TV and says the hospital food is gross ". Is this something that should be corrected or is it just a matter of opinion on what is good vs. Bad documentation.

[purplegal]

This is something that you probably should address. Not only is that information not important, but it is distracting. It fills up the charting system and could hinder someone from finding truly important information in an emergency. You should acknowledge that the PCT is making an effort to record observations, but you should review what needs to be included and what can be left out. Statements that include the patient's opinions only and not any actual symptoms or changes in their condition, like you stated above, should be left out. As far as spelling and grammar, remind the PCT to double check their work before submitting it. Depending on how bad it is, that could affect the care a patient receives in an emergency as well.

[Pangea Reunited, ASN, RN]

...doesn't sound great, but I don't think I would make an issue of it if it's under the charter's name. I work with some nurses who chart like they're drunk texting.

[Davey Do]

"patient sitting in chair eating a piece of candy, does not like what is on TV and says the hospital food is gross ".

Well, if the Patient is unable to transfer themself, is diabetic, has no TV in their room, and liked the Hospital food, I'd say you had a Psychosis NOS axis I, DM axis III, and the charting would be relevant.

Otherwise, it's superfluous.

[KatieMI, BSN, MSN, RN]

The first thing that needs to be changed, IMH (umble)O, is requirement for PCAs to write down hourly observations.

The person in question is a tech. She cannot do assessments in the sense nurses or doctors do them. What, exactly, she is expected to write down except of what she sees ("sits in chair") and hears ("I hate those rubbery eggs! Can you tell my nurse I want something for ma'pain?")? Sorry, but even 2 min she spends on this utter nonsense multiplied by the number of patients in her assignment (probably close to 10?) takes 20 min out of every hour. That is 1/3 of the time. Think about it. 1/3 of the time YOU run around to fluff pillows, fetch water and clean stuff up while your tech could do it all and let you finally do your job for real.

Reg. grammar, I would not make it an issue. It may be whatever from mild dyslexia to poor schooling X years ago, and in any case this can wait. The primary issue, again IMHO, is unclear expectations regarding a policy which appears to be half dropped already, if only one tech dutifully follows it. So it is about time to get your leadership team together. Changing to a simple graph sheet with cells to mark "yes" or "no" every hour will fulfill the function of "something has to be charted" and eliminate grammar issues as well.

[klone, MSN, RN]

Yes, it should be addressed. I agree with Katie that the first thing to be addressed is whether a PCT should be doing any narrative charting in the first place. It would seem that that could address the issue right there by saying "PCTs do not do narrative notes."

If it is appropriate for PCTs to be doing narrative notes, then absolutely the quality and content of the notes needs to be addressed. It's not appropriate, and should be stopped, and the PCT needs to be re-educated in appropriate note-taking.

Grammar and spelling, I would not address other than saying "Everyone needs to use the EHR's spell-check function." Beyond that, you're addressing something that likely cannot be fixed or changed. Either she knows proper grammar or spelling, or she doesn't.

[KatieMI, BSN, MSN, RN]

Where I work, techs do narrative notes only in cases when anybody who enters the room has to write down everything what was said, heard, smelled, seen or done. Thanks God, it happens rarely, either with threats of lawsuit/other safety issues or if patient steadily drifts into acute psychosis with unknown differential and we know that mental health people would like to know what and how he was reacting on stimuli. Otherwise, techs charting perfectly suited for "yes/no" format.

(P.S. no joke about "smelled". One time I was staying there puffing and wheezing and wondering if I got poop "aroma" as my new asthma trigger. After a while, I decided to get a second look, or rather sniff, at the issue, and promptly found the patient enjoying his MJ joint in the bathroom. I was really glad because acute care nursing doesn't sound a as a good idea for someone needing inhaler after smelling "this").

[FloatRN19]

Worry about your own charting.

[Anna Flaxis, BSN, RN]

I can't answer "yes" or "no" in your poll, because I don't think this is a black or white issue.

If your institution has an hourly rounding policy, and documentation requirements include an observation note, then I don't think it's necessarily inappropriate for the tech to follow institutional policy by entering a note. If the entries are truly riddled with errors, I don't think it would be unreasonable to gently coach the tech to use the spell-check function.

As far as the content, this information *could* be relevant. If the patient's behaviors are disruptive to the unit, if the patient's mentation is in question, if the patient is a fall risk, if the patient's dietary preferences have not been addressed in the plan of care, etc etc etc, then this is all relevant information.

I think that in this day and age of click-boxes in the EHR, that the narrative note serves an essential function. The narrative note paints a picture of the patient and their situation that all the click-boxes don't. I think hourly observations should be charted, even if it's just a brief "resting quietly, denies needs at this time". It only takes a few seconds to do, it is helpful for charge nurses, physicians, house supervisors, and other folks who might be needing to know what's going on with any given patient and don't have time to go digging through the chart to look at all the click boxes and decipher what they could mean about the patient's condition, and it could really save your bacon in the event that a patient or a family member claims that you were never in the room or that you didn't address certain issues, etc.

Some people argue that it is double charting; ie if my neuro assessment says they were A&Ox4, my musculoskeletal assessment was WNL, then why should I document a narrative to that effect? Or, the record shows I was in the room giving a medication, why should I also document that I was in the room in a narrative note?

The reason is that notes paint a picture of the patient's course of illness and the notable events during their stay in a way that click-boxes do not. The chart might show that you did an assessment or that you were in the room giving meds, but it does not give an impression of what the patient looked like at that moment in time. No, you don't have to chart every time they fart sideways or have an itch on their backside. The narratives should be relevant to the patient's specific situation.

So, in a nutshell, if the tech's notes do not contain relevant information, then they need a little coaching on what should and should not be a part of the hospital chart. But if the notes are relevant to the patient's situation, then your narrative notes need to contain relevant observations too, and show that you followed up on anything the tech might have noted.

Something that drives me nuts when people chart, is when they chart subjective feelings, like "patient is angry". Don't do that. Chart behaviors, like "patient pacing back and forth with fists clenched, states loudly "This place is horrible! I can't get any rest!" (and document what you did about it). Another one is when nurses chart "patient aware" or "doctor aware". How do you know what the patient or doctor is aware of? Instead, chart "plan of care explained to patient, patient verbalizes understanding", or "doctor notified, new orders received (or no new orders received, whichever is the case)".

Anyway, I support the tech entering a brief observational note, if hourly rounding documentation is required at your facility, and I support you coaching the tech in using spell check and making sure the content of their notes is relevant and appropriate. For hourly rounding, typically you just want to show that the "Five Ps" (or whatever criteria your institution has laid out) were addressed.

[klone, MSN, RN]

Worry about your own charting.

Disagree. The RN is in a supervisory position over CNAs and techs. As such, coaching is appropriate.

[verene, MSN]

As a tech I chart hourly on all my patients (unless 1:1 with restraints then I chart every 15 minutes). Much of what I chart is a simple matter of check the boxes (up to bathroom, sitting up in chair, etc), but sometimes there are other notes to be put in because the most relevant things going on with the patient isn't a box ("pt complt of severe abdominal pain and nausea; RN notified"; "Pt working on craft project with volunteer" ); there are safety issues (e.g. for a high fall risk patient - "family repeatedly request chair alarm be turned off"), behavioral issues (pt reports his agitation and need to leave "right now" stems from concern for pets left home alone; CM to follow up with POA per pt request); or to back up my nurse with a difficult family/patient (family req X, RN responded to concern at Y by Z).

Lots of spelling errors and personal opinions on patient behavior or feelings is unprofessional. Remind the tech that notes need to be based in fact. "Patient sitting up in chair watching TV" is a fact. "Patient upset" is interpretation of demeanor a better report is "Pt tearful, reports feeling upset about X"

[Anna Flaxis, BSN, RN]

Agree with above ^^^

Also, I'd like to add that complaints about food or other things speak to the patient's mood, which is a part of a behavioral health assessment. If behavioral health is called in to see the patient, it's really helpful to have some information on the patient's mood and behaviors. Quoting the patient in their own words is good practice.

As a House Supervisor, I get called when patients are threatening to leave AMA. It's really helpful when there is documentation of behavior leading up to that point, ie what the patient said or did, what the staff said or did, whether we attempted to make reasonable accommodations, etc. When the patient is found dead from an acute GI bleed under a freeway overpass, it's really important that we be able to show that we did our due diligence to meet the patient's needs. It's really frustrating when there is not a single note in the chart for an entire shift or two leading up to that moment when the patient walked out the door.

Or if Grandma falls while trying to get back into bed from the chair, where is the documentation that somebody spoke to her about safety, made sure she was wearing nonskid socks, made sure the room was free of clutter, and made sure the call button was within reach? What was her mental status at that time? Was she known to be impulsive, or was she completely A&O and able to make her needs known?

So again, observations about behaviors are not necessarily irrelevant, and the person making the observation (RN, CNA, Tech) is qualified to enter it into the record in accordance with institutional policy.