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.

[cjcsoon2bnp, MSN, RN, NP]

To the OP, I think that you bring up a valid concern that you should talk with your manager about. There are actually a few questions at the heart of this issue and this could be a good starting conversation about documentation.

1. What should nursing assistants (CNA/NA/PCT) be documenting in the electronic medical record (EMR)? Narrative notes? Checkboxes/flowsheets to document the "5 Ps" and other basic care items are addressed? A combination of both?
   
2. What training do nursing assistants have in documenting at your facility?
   
3. Who audits/reviews the documentation of nursing assistants and who is responsible for following up with an individual when documentation isn't done or is insufficient?
   

When I first read your post I thought that this is a matter of some staff re-education and presents some great opportunities to look at system and quality improvement. As I mentioned, first talk with your manager and bring up the issue tactfully and then ask if you can be a part of the discussion about the issue and some possible solutions.

If a checkbox/flowsheet system isn't available or what your facility wants to use them in the EMR then perhaps you can work on coming up with a few scripted statements that are posted to help nursing assistants with their documentation (e.g. "Patient offered to use bathroom with PCT assistance, patient declined needing to use bathroom at this time."; "Bed remains in low position, call bell within reach, non-skid socks remain on patient, bed alarm activated and room environment free of debris."). Another option is that as a staff nurse you could help come up with an educational training or competency for the nursing assistants about documentation and include some case studies/scenarios that they could be asked to come up with some sample documentation (this would look great on your resume as well). Great discussion started by the OP, best of luck!

!Chris

[MaxAttack, BSN, RN]

Is it a policy to chart hourly observations? If so, it sounds they threw it into place w/o really thinking it through or educating the staff on what they're looking for. PCA's can't chart an assessment of the pt's condition, and she's technically charting observations so you can't fault her for trying.

Bring it up with your manager. Hopefully they can offer guidance and you can help not just this situation, but the rest of the floor as well.

[Mscoleman78]

At the nursing home I just left a nurse quoted exactly what a dementia resident stated while charting. The resident stated that she had been having sex all night long (but the nurse used the 'F' word because that was the resident exact words). The nurse was sent home and almost fired because of her charting and she also didn't notify the administration about this. I personally felt it was a more professional way of charting the incident, but the nurse said as long as it's a direct quote in quotation marks then it's fine!!!

[psu_213, BSN, RN]

I have mixed feelings on this one...

As someone alluded to, "unnecessary" charting can muddy the chart and make it difficult to find necessary information in an emergency situation, should one arise.

OTOH, there is the issue of hourly rounding. At one facility, we had a sheet on each door that was initialed by the RN or PCT to "prove" that someone was in there each hour. Many times, people would just initial for each hour at the end of their shift. An initial did not prove someone was in the room at any given hour, nor did lack of an initial prove that no one went in to the room that hour. Eventually the sheets were discontinued and if there was an issue, management would go to the chart. If the PCT from the OP had been "called out" on not going his/her hourly rounding, it is not a surprise that he/she writes a more detailed note each time they round on a patient.

So once again, there is a conflict between customer service and quality patient care/safety. Again, what if this customer service charting prevents quick access to information during a code? Or, in an attempt to seem attentive, the PCT charts "large pitcher of ice water at BS," and it turns out the pt. is on a fluid restriction. Perhaps the pitcher of water is not there, but this is just a standard line the PCT uses to show they were in the patient room and that "comfort needs" are being met; however, this isn't going to look very good if this chart ends up in court.

I think it is appropriate for PCTs to write short narrative notes, but I think they need guidance on what should be (and should not be) charted in such notes.

[RestlessHeart]

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.

As someone who pours over medical records ...by the hour sometimes....and for legal reasons most of the time...this tech needs to be educated...gently. Superfluous information and spelling errors, even the average syntax in medical records can be misleading and detrimental. Nothing is more annoying and aggravating than reading a medical record, which IS a legal document that is riddled with mistakes. It has the potential to change the outcome in some instances. Granted it may be nothing major for others but from my end of things it's a bit of a big deal. I wouldnt bust on the tech too badly but do bring it to her attention.

Have a stunning day