Very frustrated. Redundancy in charting, OT

[lisamc1RN, LPN]

I am an LPN in a LTC and have been at this facility for 2 + years. I really do love my job, and pride myself on being a well organized nurse. However, occassionally I find myself in a place where I am working overtime, which my DON doesn't like, of course. Typically, this has been due to charting. The past 3 days, I have had the hardest time getting out of there! I have left 1 1/2- 2 hours late each day. My DON came up to me and basically stated that I was spending too much time there. I apologized and explained that I was overwhelmed with all of the charting and Incident reports, etc that still needed to be filled out. She was very understanding and concerned about how to make this better.

On to this morning. I have a new unit manager, who I spent about an hour with this morning (when I thought I was caught up. Hah!) and showed her some of what we do back on my unit (I work on the behavioral unit). She asked me a very good question, and one that I have asked several times over the past 2 years. Why, oh why, am I charting in 3 places, a person's behaviors? Why I am posting VS and weights in 3 different places? Why I am having to chart my prn's, the reasons given and effectiveness not only in the backside of the MAR, but in my nurses notes? Why I am I doing monthly summaries on this sheet of paper that takes up 15 minutes or more of my time, for each resident, every single month when ALL of that information is charted somewhere else? For example, on my monthly summary, I must chart diet, diagnosis, vital signs and weights, wounds and treatments, etc. This document is front and back. All of these items are found somewhere else in the chart at LEAST once. Why??? I have still not received any answer that makes sense to me.

For instance, the DON before this one stated, if the nurses would just document in the correct place in the first place, we wouldn't have to do this. Why not enforce it in the one place rather than create yet another place for someone to miss? I truly feel overwhelmed, frustrated, and sometimes even a bit peeved about all of this. It is enough to do when, like today, I have to fill out an incident report for a fall, neuro checks, I have someone who is vomiting, 2 that are screaming, punching walls, and generally being difficult, along with all of the routine bits of my day, just to fill out one piece of documentation.

I'm genuinely asking why? Is it a state mandation? Is it better for us to have more documentation? What if I signed in one place that I did such and such, but didn't in the other? Am I covered? Or is this do to a poor documentation system in place? Or policy of the facility to CYA and theirs?

[florianslove]

Honey, I feel your pain. We now are using OPTIMUS EMR charting. It is a nightmare. Nurses have to chart on general observations for every resident at least once a week. This is basically MDS information. The progress notes are ridiculous. We also have to do daily skin checks, daily shower sheets, weekly skin checks and on and on. Every bruise is an incident report which is five pages, the MD must be called as well as the family for EVERY bruise and skin tear. Then it must be charted under incidents/occurrences in the EMR.

This takes forever, as a Unit Manager I try to help the hall nurses as much as possible by at least doing their incident reports. These nurses also have 30 residents to pass meds to, do breathing treatments, etc, etc.

Our DON also doesn't want to have overtime show up, but how are you going to stop it?? I don't know what the state requires, but the charting is insane.

Good Luck,

Roxann:crying2::grn: