Why is charting so difficult and time consuming?

TazziRN, RN · Jan 9, 2007

It's time consuming because of lawsuit-happy people. We have to chart every single time the pt sneezed and what it looked like, because the one time we don't, something negative will happen to the pt and we can't prove we did what we were supposed to because it's not charted.

AuntieRN · Jan 9, 2007

OMG I hate to chart...it is the worse part of my job. It's long, tedious and very time consuming....but like Tazzi said....it is because people are so quick to sue. If it is not charted it was not done or did not happen.

htrn · Jan 9, 2007

IV start - charted 4 different places - IV started with 18 guage accuvance, 1st attempt, left arm, 1% lidocaine used for analgesia, LR 1000ml at TKO.

Newborn Hearing screen - charted 9, YES NINE, different places

That, and everyone wants an excuse to sue, or we have to assume they will. Defensive Medicine.

feisty_lpn, LPN · Jan 9, 2007

Its the repetitive charting I hate... the same information in 10 different places. But because of I'm scared to death of a lawsuit and the BON, I chart like I'm going to be sued the next day. I even chart on patients where no charting is needed for that shift... IE: "resting quietly with eyes closed, laying in supine position with HOB @ 30 degrees." etc etc. (I work noc, btw LOL)

oramar · Jan 9, 2007

I long for the old days when we charted by exception. Once a day a head to toe was done and from then on it was by exception(exception means a change for the worse or better). Now on med/surg they want head to toe charted every four hours, rehab at least is still head to toe once a shift. It is so time consuming and tedious to repeat and repeat the same information over and over again. I for once have about had it with the whole business of nursing and especially charting.

Indy, LPN, LVN · Jan 9, 2007

Well that is just ridiculous. I'm there for 13 hours, and I'm only doing a head to toe assessment once, unless there's some kind of major emergency. So why in the name of saint peter's lunchbox, would I wake up my patients at midnight and four AM to do another head to toe on them? That's completely crazy.

RNperdiem, RN · Jan 9, 2007

There is a cumulative overload of charting. Looked at individually one piece at a time, it is not much, but multiply every restraint documentation sheet, admission chart, seperate forms for epidural pumps, separate flowsheets for the morphine PCA, transfer checklist forms, patient discharge paperwork, and the patients outcome nursing notes that doctors and most nurses never read. Now multiply those forms by the number of patients you have. Now add chart auditors who will cite you for anything not complete. Now add all the nursing duties that must get done in a day.

cardiacRN2006, ADN, RN · Jan 9, 2007

I have a nice open flowsheet where I only chart on the bottom. I actually chart very little. I chart when I called Drs to inform them of pt changes, what their reponse was, when I started new IVs, or when new Central lines were placed. The only time I ever chart in a progress note is with a new admit. Then I just do an admit note.

Othewise it is curt and to the point. 1100-Dr smith notified of HR, BP & UO, orders received.

My flowsheet shows when the bolus started, as does the MAR. I don't need to write a note about it as well. But, I have to do a head to toe Q2 hours, so lots of my info goes there...

CIRQL8 · Jan 9, 2007

IV start - charted 4 different places - IV started with 18 guage accuvance, 1st attempt, left arm, 1% lidocaine used for analgesia, LR 1000ml at TKO.
Newborn Hearing screen - charted 9, YES NINE, different places
That, and everyone wants an excuse to sue, or we have to assume they will. Defensive Medicine.

CRAZY!! the more places the same thing is documented (esp. if by different people), the greater the chance of contradiction. THAT is what makes the lawers happy.

CIRQL8 · Jan 9, 2007

In God we trust - all others must document. :)

RazorbackRN, BSN, RN · Jan 9, 2007

I have a nice open flowsheet where I only chart on the bottom. I actually chart very little. I chart when I called Drs to inform them of pt changes, what their reponse was, when I started new IVs, or when new Central lines were placed. The only time I ever chart in a progress note is with a new admit. Then I just do an admit note.
Othewise it is curt and to the point. 1100-Dr smith notified of HR, BP & UO, orders received.
My flowsheet shows when the bolus started, as does the MAR. I don't need to write a note about it as well. But, I have to do a head to toe Q2 hours, so lots of my info goes there...

Same here.