Who reads your charting?

Nurses General Nursing

Published

With the exception of a few auditors and maybe the wound care nurse, the only people who routinely read my assessments are other nurses. My MD's will check out the tele strips I post and look at flowsheet data, but otherwise don't read our charting.

Who reads your charting?

CathyLew

463 Posts

Specializes in MSP, Informatics.

with my handwriting and spelling...hopefully no one!

oregonchinamom

80 Posts

Specializes in ICU, Education, Peri-op.

Make no mistake about it, LAWYERS read your charting! Nursing notes are the very first place a lawyer looks in a medical chart.

If you haven't done so, I reccomend you take a course on defensive charting. Those classes are eye-opening!

Texas Tornado

51 Posts

Make no mistake about it, LAWYERS read your charting! Nursing notes are the very first place a lawyer looks in a medical chart.

If you haven't done so, I reccomend you take a course on defensive charting. Those classes are eye-opening!

I read you loud and clear on the CYA aspect of charting, and that class sounds like it would be great.

Having said that I somehow felt better thinking my time and effort was actually contributing to patient care.

:o

netglow, ASN, RN

4,412 Posts

Oregon, were you able to take any of those courses online? Or were they offered at your facility or conferences? I'd love to take one as I am nearing the end of school will graduate soon.

pattymac

100 Posts

As a research nurse I read your charting!! 'Cause I know that's where the best/right stuff really is... :)

Texas Tornado

51 Posts

As a research nurse I read your charting!! 'Cause I know that's where the best/right stuff really is... :)

What exactly are you researching? A specific patient and their care, or is it more global, like auditing for statistical purposes??

It's good to hear someone out there is reading them :)

mizfradd, CNA

295 Posts

Specializes in med/surg, psych, public health.

Besides the state auditors who usually come quarterly but are known to bee-bop in any ol' time for a surprise visit, there's the NS, ANP's, RN's, LPN's & other CNA's who read my charting due to mandatory peer review meetings bi-monthly.

We really do learn a lot from these reviews!

And occasionally we'll also get a research nurse like Pattymac... doing statistical and/or epidemiology reseach.

Specializes in CVICU.

Actually, with our new computer system, I do see some docs reading my narratives... it's actually nice because then they have a clue about what the patient's night was like.

blondy2061h, MSN, RN

1 Article; 4,094 Posts

Specializes in Oncology.

Everyone in daily, multidisciplinary rounds.

iriska_meller

58 Posts

Specializes in Diabetes, Primary care.

Some of our docs don't even read other docs' notes. The last night I worked one of my patient nearly coded, went bradycardic to 20s, passed out, etc. He recovered, thankfully. the night resident left a nice long detailed note in the computer. The attending comes at 7:30 and I have to literally chase after him to tell him what happened overnight, and put his nose into my charting and strips, because he wouldn't believe it otherwise. God, could you prepare before you come to see your patient?

honestly, I feel that 99% of my charting is for my protection, cause no one bothers to read them...

binker4

2 Posts

Therapy, and MDS people read your chart as well

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