Why don't you just read the chart?

lrobinson5 · Jul 15, 2015

Ah yes, because no one has ever forgotten to chart an IV, or that the patient peed, or has a stage IV wound on their sacrum. ER can be just as crazy and I don't expect perfection. I do expect answers to my questions because it helps me prepare for the incoming patient. It might also help the very busy ER nurse realize that they did forget to chart XYZ, or also trigger a memory that something should be passed along. "Oh yeah, the patient didn't pee, that's because I forgot to tell you he's a dialysis patient." Sometimes I have more time on my hands and I review the chart before I get a call from the ER. I still ask questions even then.

For instance, Vancomycin charted as being given at 2300. Get a call from ER nurse and find out that they basically stopped the infusion at 2315 for MRI and a slew of other tests. There isn't a way to document this, so I would have been surprised and maybe even filled out an event report when the full bag came up with the patient.

We aren't asking questions to make your life miserable. It really is in everyone's best interest: mine, ER nurse, and patient.

target98765 · Jul 16, 2015

And at the end 9f the day, the single most important thing you do is give a complete, through hand off report. This is a JACHO focus.

FlyingScot, RN · Jul 16, 2015

As a teen, I worked at a local gas station part time. It was perfect for me, I was considered the extra helping hand. My hours were always evening, starting two hours before the deadline for playing your lottery numbers and ending one hour after. I mostly did lottery and other odd jobs other people just never seemed to have the time for.
The man who worked evenings was an interesting case. Very much a believer in getting along with coworkers. He became a friend of the family in fact, came to my HS graduation. I thought him odd at first though for a number of reasons:
1. On the nights I wasn't there, if the lottery customers became too much to handle, his solution was to pull the key out of the lottery machine and hang a sigh that said "Sorry, no lottery today." The manager would literally scream about this the next morning and threaten to fire him every time. He'd inform her he couldn't handle evenings alone and if there wasn't a "helping hand", he wasn't going to make himself crazy trying to do the work of two. She'd end it with another threat, he'd shrug it off and do it again.
2. He never talked about teamwork, he just did it. His number one concern was that we (as in me and him, the workers and the customers) were safe. After that, he got as much as he could done but he never seemed stressed.
3. He never bad mouthed the company, but at the same time you could just tell they didn't "own" him. He was loyal, to a fault at times, but he kept things in perspective. He was quick to decline new responsibilities if he felt he couldn't really do them, but always eager to make the place run/look great.
Being a gas station attendant is super hard work. People always wonder why they are all so grumpy and stand off ish. You not only have to attend to the customers, and it's never very long between one and the next........but the manager forever leaves mile long lists of things for each shift to accomplish on the side of taking care of customers. Paperwork, stocking the cooler, cleaning, ordering things in and all sorts of stuff. It gets to the point where you can lose your perspective and common sense goes out the window. You get so engrossed with "the other stuff", you start to treat the customers like a nuisance. You feel too busy for the things that matter most, because you're head is spinning with all the things that need done and not getting them done makes you feel insufficient.
I want to preempt this with, I don't mean to sound like I'm on a soap box and I'm not talking directly to anyone in particular, but this whole thread has me shaking my head. The ER nurse posts some frustrations with hand off report, the floor nurses jump down their throat and the whole "Unit A vs. Unit B" war starts.
I think both sides miss the point a good bit. It has nothing to do with the report, how long it takes or what kind of questions are being asked. It seems plain to see, to me, that if you are to the point where giving hand off report is "in the way" and you're too busy, there are problems that transcend how well the floor nurse receives report going on. It's like I was at the gas station, so insistent on getting my tasks done according to the manager's plan, essential things like........oh, I don't know......collecting payment for gas from the customers started feeling like a bother.
The gentleman I worked with had the right answer too, in my opinion anyway. He took the problem to the ones who could actually do something about it. He did what he could with what they gave him, made no apologies and put the ball in their court to correct it. When they didn't, he didn't stress it, he just continued doing the best he could.
I do believe on some level, administration likes the fact that we turn on each other instead of them. Somewhere, I can picture a CEO of a major healthcare provider chuckling and puffing his cigar as he reads this. Truth is, we're all stressed and have too much to do, too little supplies to do it well and no support for when things don't go according to plan. Grabbing each others throats over details about report giving isn't going to correct any of this. But, we're afraid of the administration, they can fire us. On the other hand, popping off at the nurse from another unit about a mistake or oversight that takes two seconds to fix presents no threat to us.
That makes about as much sense as, well, imagine if the gentleman at the gas station were to holler at me all day long because I couldn't come in every day of the week to be the helping hand. It's directed at the wrong person, the company should be giving him enough help.
Which takes me back to something I talked about in one of my first posts here. My first preceptor ever drilled it into my head to get along with other units and other workers because at some point, you're going to need them. I like to think, when the ER calls the unit to give report, they're glad to hear it's my voice when I say "Oh, I'm the nurse, let me grab a pen." I accommodate them in every way I can. I don't make remarks about how it's the end of the shift, point out mistakes or any of that. I ask for pertinent information if it's not given and if they don't know, I'll find out myself (by reading the chart , yes, I can do that).
I don't do this for altruistic reasons though. I'm very selfish. I have a firm belief that ER nurses start to recognize your voice and know who you are. I want good karma with them, for sure. My hope is, since I'm not a thorn in their side, I can cash in my chips when I need to. And I have. I do say "I simply can't take an admit right this second. If it's not unsafe for you, can I have thirty minutes." They oblige me more often than not. Had a nurse, on her way to lunch, leave with a terrible hand off report that included "I think my guy in room 102 might code, keep an eye on him." Yeah, my team was super busy and she leaves me with a patient that she thinks is gonna code soon. She's gone five minutes and the ER calls to tell me an admit is coming. I was super uncomfortable. I told them my situation. The ER nurse asked when my coworker left for lunch, and sent the patient five minutes after she was due back.
That's how my friend from the gas station would have done it. "Turn around times" ceased to be a priority because, well, obviously there wasn't enough help and things were going downhill for us on both sides. If turn around times aren't enough of a priority to the admin., at least not enough that they staff a little better, how can it be a priority to me (well, the ER nurse in this example)?
I just wish we'd sometimes take the venom and nail spitting that goes on in here to the people who deserve it. I don't think we deserve it, not from one another anyway, we're all trying our hardest.

This!!!! A million times over!!!

AliceTrout · Jul 16, 2015

You are making a lot of assumptions here. Again, there is no advantage to holding an admit patient until shift change. It does not prevent the ED nurse from getting a new patient like it does the floor nurse. In fact, it makes the job even more difficult because you have a cheesed off admit patient waiting on a hard cot without a bathroom or a TV and you are now providing care to an additional patient in a hall bed.

I am comfortable in the assumptions I am making because I know the people I am talking about, and what hospital I am talking about, and what policies and amenities this hospital has. Knowing all of that, I am utterly confident in my claim that that 1 or 2 bad apple is doing exactly what I claim.

I see from your response that your facility must be a little different. For example, all our ER patients once they go back get their blessed tv and real bed. They are comfortable. And as 7/10 times I am admitting a ventilated patient, that means that per our policy, that patient is the ER nurses ONLY patient. Trust me, the bad apples do NOT want to give that gig up. His or her ER COWORKERS probably want them to, but that particular nurse is in vacation station. Which is the final reason I know they do it. THEIR FELLOW ER NURSES TELL ME. Usually in anger vented over a beer. Cause that's a dirty way to do your buddies in the trenches.

Again, I mean no disrespect whatsoever to the great ER nurses I know out there. Let's just acknowledge that every floor/unit has some crappy coworkers. ER included. No need to blindly defend every nurse nationwide that works a particular unit. :up:

FlyingScot, RN · Jul 16, 2015

I am comfortable in the assumptions I am making because I know the people I am talking about, and what hospital I am talking about, and what policies and amenities this hospital has. Knowing all of that, I am utterly confident in my claim that that 1 or 2 bad apple is doing exactly what I claim.
I see from your response that your facility must be a little different. For example, all our ER patients once they go back get their blessed tv and real bed. They are comfortable. And as 7/10 times I am admitting a ventilated patient, that means that per our policy, that patient is the ER nurses ONLY patient. Trust me, the bad apples do NOT want to give that gig up. His or her ER COWORKERS probably want them to, but that particular nurse is in vacation station. Which is the final reason I know they do it. THEIR FELLOW ER NURSES TELL ME. Usually in anger vented over a beer. Cause that's a dirty way to do your buddies in the trenches.
Again, I mean no disrespect whatsoever to the great ER nurses I know out there. Let's just acknowledge that every floor/unit has some crappy coworkers. ER included. No need to blindly defend every nurse nationwide that works a particular unit.

The problem is you are speaking of one and only one person you know in the context of a thread that has turned to accusing ED nurses, in general, of holding onto patients when this is just not true. You're adding fuel to the fire that's burning them at the stake. Again, have you heard even one ED nurse here accuse the floor of playing games to avoid taking the patient? No, you haven't and we expect the same courtesy.

Guest219794 · Jul 16, 2015

Contrary to the allergy to assessment that many ED nurses seem to have, you are responsible for knowing what's going on with your patients (including where their IVs are and approximately when important meds were given). As you mention, not everyone has access to the charting from the ED, but most of the time I find that easier to follow than the useless reports I get from the ED that make me wonder if anyone has actually looked at the patient.
See, this **** cuts both ways.

Actually, I am not responsible for knowing where their IVs are. I am responsible for having the skill to locate them. Which, as luck would have it, I do. It is especially easy when an IV is running, I just follow the tubing, and there it is. Of course when nothing is running, it requires some sleuthing- I usually check the arms first.

As far as knowing when important meds were given? Good point here. It's not a huge help for me to be verbally told this, as it is quite easy for me to scan the MAR. Since I read faster than most people speak, it saves both me and the off-going nurse time.

Regarding useless reports from ER nurses? This is an excellent point, and I am glad you bring it up (though it may have been mentioned in this thread earlier). The jobs are very different, and the ER nurse looks at the patient very differently than the floor nurse. Personally, I try to make report an informative and positive experience by looking at it from the floor perspective. This is why I access the chart as I give report. The same chart the floor nurse could be accessing, and getting the same information faster.

And, thank you for supporting my point that it is easier and more accurate for you to read the chart. Also, thank you so much for actually, reading it- It saves us both time. Otherwise, I will have it open on my screen and be scanning it as we speak to verbally tell you, which would be a little silly. This is why I start report by asking if we are starting from scratch. It is a non-judgmental way to find out whether the receiving nurse has scanned the chart. It seems that if I ask directly, it invokes a defensive response. And, if the receiving nurse has spent a short time getting the well documented details, we can focus on the big picture and my subjective impressions saving us both valuable time.

Your final point "See, this **** cuts both ways." has me baffled. First off, I am pretty sure TOS allow you use the word "knife". And, I am completely missing your point. It seems like you are saying that sometimes ER nurses don't do a good job. OK, I'll buy that. How does that relate to you maximizing your time and energy by reading the chart?

nelcoy4 · Jul 16, 2015

At my facility the ER nurses don't give floor nurses report. We (floor nurses) get a 20 minute notice that a patient is coming. The whole facility uses Epic, so as long as stuff is documented it is easy to read the chart.

My issue is that there has been times when the unit clerk or charge RN forgets to tell me that I'm getting a patient sometimes. They will tell us when the patient arrives. Now I'm rushing reading the chart while I'm trying to get the patient settled. I wish we had a nurse to nurse notification/communication that a patient is coming.

daniellenursing · Jul 17, 2015

One of my biggest pet peaves is "where is there peripheral IV in their arm"? I have serious concerns about a nurse's basic thinking process when they consider that to be a relevant question on report. It's the brightly colored thing taped to their arm.

I ask where the IV is if it's a new patient to me because A: how many times have I seen an IV pulled out??! B: the chart is about 50% incorrect when it comes to IV site, gauge, and orientation. Sorry, but I want accuracy. It's not that hard to tell me they have a port, a central line, a PICC, or a peripheral in the left wrist that is infusing with NS at 50mls/hr, cause man when I get my first look on that patient I'm gonna assess per the chart, per report, per orders, and take into consideration the patients baseline and then changes in that baseline.

How is asking about where an IV is and infusions associated with that such a big deal? How is my critical thinking and processing an issue when asking? I can ask any question I want.

And ugh, don't get me started on the OP. While I can look at the ER chart before the patient comes up, I may not have time to. I need that report via phone at the least. The chart can be very inaccurate, when I'm sure in emergencies most medications aren't scanned via barcode, and even our rapid response team forgets to document a medication pulled emergently (so I come on five hours later to find it not documented via the MAR, but I do know it was given via the bedside report). I try to use the chart with report. It's what my preceptor taught me and guided me on. Because sometimes the chart is confusing. Like blood transfusion parameters, what's been treated (was potassium/magnesium/phosphorus replaced?). So much faster asking the actual person than looking in the chart. And mind you, I am a wiz on the computer. I am lightning fast on the computer, but retaining a ton of information is sometimes difficult for this clinically depressed brain!

VANurse2010 · Jul 17, 2015

Actually, I am not responsible for knowing where their IVs are. I am responsible for having the skill to locate them. Which, as luck would have it, I do. It is especially easy when an IV is running, I just follow the tubing, and there it is. Of course when nothing is running, it requires some sleuthing- I usually check the arms first.
As far as knowing when important meds were given? Good point here. It's not a huge help for me to be verbally told this, as it is quite easy for me to scan the MAR. Since I read faster than most people speak, it saves both me and the off-going nurse time.
Regarding useless reports from ER nurses? This is an excellent point, and I am glad you bring it up (though it may have been mentioned in this thread earlier). The jobs are very different, and the ER nurse looks at the patient very differently than the floor nurse. Personally, I try to make report an informative and positive experience by looking at it from the floor perspective. This is why I access the chart as I give report. The same chart the floor nurse could be accessing, and getting the same information faster.
And, thank you for supporting my point that it is easier and more accurate for you to read the chart. Also, thank you so much for actually, reading it- It saves us both time. Otherwise, I will have it open on my screen and be scanning it as we speak to verbally tell you, which would be a little silly. This is why I start report by asking if we are starting from scratch. It is a non-judgmental way to find out whether the receiving nurse has scanned the chart. It seems that if I ask directly, it invokes a defensive response. And, if the receiving nurse has spent a short time getting the well documented details, we can focus on the big picture and my subjective impressions saving us both valuable time.
Your final point "See, this **** cuts both ways." has me baffled. First off, I am pretty sure TOS allow you use the word "knife". And, I am completely missing your point. It seems like you are saying that sometimes ER nurses don't do a good job. OK, I'll buy that. How does that relate to you maximizing your time and energy by reading the chart?

As usual, you people take no responsibility for your patients. I've made no secret of my opinion of ED nurses.

nursej22, MSN, RN · Jul 17, 2015

Wow, so much nurse against nurse hostility! And IMHO this misplaced anger and frustration should be aimed at the system and administration. Of course, several posters have commented on this.

1. Two different, incompatible electronic charting systems. D'oh!

2. Understaffing to the point that a nurse must choose between essential bodily functions or taking report. Did you ever notice how much more clearly you can think when your bladder is empty?

3. Not enough housekeepers to turn rooms around for the admits coming. I often used to come in at 3pm, with 10 admits to place, and 0/12 beds clean and ready. Arrggh!

4. Speaking from a cardiac tele perspective, we would get patients from ED, PACU, medical, surgical, cath lab, and direct the clinic or home. Again, often at 3 pm, and again, no clean beds. I can't remember how many times the ED complained about me giving away "their" beds. Dude, I am taking the CHFer direct, so you don't have to, or i'm taking the ICU transfer, so they can take one of your admits.

5. So many newbie floor nurses who are not yet comfortable accepting patients without knowing every little detail.

6. So many newbie ED nurses who don't realize just how sick their patient is.

6. ED MDs and PAs who do their dispos at the end of their shift.

7. Hospitalists who do write discharges at the end of their shift.

IV size and location were the least of my worries.

So happy to done with bedside nursing.

Guest219794 · Jul 21, 2015

As usual, you people take no responsibility for your patients. I've made no secret of my opinion of ED nurses.

You mean all of us people, or just most of us?

In your opinion, why does the field of emergency nursing attract such lazy, uncaring people?

Guest219794 · Jul 21, 2015

Curious about perspectives on a situation.

I come in mid-day to relieve a coworker in the ER who is working half a shift, take over 4 PTs.

It is a busy fast track section of the ER with a goal of a maximum 1 hr turnaround, but occasionally you end up with an admit.

I get a very brief report: Pt is a walk in being admitted for complications of a surgical wound for observation and IV abx. First round of abx have been given, the pt doesn't need anything, we are just waiting for a call back from the floor.â€ While this may sound unusual to non- ER nurses, this is all the info I need to be told. While it's possible I will need other info, I can find it out very quickly.

I walk into the room, introduce myself, acknowledge the wait and the uncomfortable stretcher, let the pt know I am working on getting a room. Ask if he needs anything. He does not.

I briefly scan the chart for outstanding orders, there are none. Recent set of vitals is charted.

The wound has been assessed by the ER nurse, ER doc, and admitting doc, and has a dressing on it.

My job is to get the pt to the floor, and manage my other PTs. From an emergency perspective, there are no outstanding assessments or interventions.

At this point, what do you believe is the correct course of action? Should I go and do a more in depth assessment? If so, how in depth? Should I break down the dressing, listen to lung sounds, check details of last bowel movement? Should I simply check the chart and relay the information? Should I read the chart, write down the date of the surgery, and name of the surgeon so I can verbalize this information for the floor nurse to write down?

I would like to hear, from the floor perspective, what you think the responsibility of the ER nurse is at this point.