Who reads your charting?

[Texas Tornado]

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?

[cursedandblessed]

the coder's who bill the insurance companies check every page of nurse's charting to compare it to what the doc's charting is, in order to code and get reimbursement for every dime they can. if the nurse catches something the doctor missed, they send note's over to the doc's to get the doc to add an addendum. just a little something i found out on monday. lol

[oregonchinamom]

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.

I went to a short one that my facility offered then went to an all day course outside my hospital after the first one scared the bee-jee-bee's out of me! LOL

I ended up in education for a few years and taught defensive charting. Everyone always really enjoyed those classes and the stories from the really veteran nurses were awsome!

[BeachyRNn08]

Our Department "Educator" reads our charting, nit picks it apart for things like remembering to chart "prn pain med effectiveness" or charting that we are educating our patients. Fun!

[classicdame, MSN, EdD]

I do. I am an Educator and I teach patients based on what you write.

Also, the utilization and quality nurses read them - the dietician does - and one of the coders in my hospital tells me she has to read them frequently in order to be sure we are billing correctly. So please write legibly.

[Roy Fokker, BSN, RN]

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.

Or if I've gotten to a patient before the Doc has, some of them (not surprisingly, the nicer ones :)) will do a quick read of my charting to get a quick snapshot of the patient before going in to assess 'em.

When we have problematic patients, a couple of our docs actually use/incorporate our charting into their dictation/notes as a form of 'supporting evidence'

cheers,

[Spidey's mom, ADN, BSN, RN]

One of our docs reads the nurses' notes.

Then there are chart reviews.

Insurance. Legal. Etc.

Lots of people read it.

steph

[mshultz]

I eventually requested my medical records from when I was in the hospital in 2003. It's just not possible to be an informed patient without a copy of the medical records.

[Daytonite, BSN, RN]

i worked as a medical coder. when we had difficulty reading doctor's handwriting we often went into the nurses notes to help us figure out what the doctor was saying. interestingly, some nurses writing is worse to read than the doctors! i had a nurse friend who did insurance auditing and that's all she did was review nurses notes in order to correct billing charges. if nurses didn't chart procedures then they didn't pay for things they were getting charged for by central supply. i also attended a number of law seminars during my working career. you never know when your charting is going to become of interest to a lawyer. sometimes students will ask for permission to review charts retroactively for research purposes as well and that may included going into nurses notes for some reason.

[Nurse2Doc2008]

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?

I (resident) read nurses notes 100% of the time, unless I speak at length with the nurse about overnight events! My co-residents, as far as I know, do the same....we are taught to do this in orientation. I feel like when I was nursing, I thought no one was reading them either, but I bet at least some of the MD's were reading them and I just didn't know.