It's all about CHARTING *sigh*

  1. Just reviewed four of my chart audits. Well, apparently, I didn't chart "BARRIERS TO LEARNING" on the education record. And I hadn't charted Treatment record the DATE each IV site was inserted (it was charted in the COMPUTER but not on my individual nursing note). There were a couple other things but I'm too depressed to list them.

    *sigh* It's just depressing. It just seems sometimes that it doesn't matter what kind of care you give; all that matters is what you DOCUMENT. *sigh*
    •  
  2. 12 Comments

  3. by   BadBird
    Hey Zee,

    You know that unit triple charts anyway, paper charting, computer charting, special paper charting. There is just no pleasing the paper monsters!!! Maybe if your charge nurses had to take patients they wouldn't have time to critique all your charts with a fine tooth comb.
  4. by   Zee_RN
    LOL. Badbird, you got that right. It was a charge nurse who talked to me today. In her defense, she (and the others) had come under fire from you-know-who because they weren't giving enough NEGATIVE feedback when doing chart audits!!!
  5. by   deespoohbear
    Anymore, I figure I can only do so much in my shift. Of course, I document the pertinent stuff-meds, changes in condition, new orders, etc, but hey some of this stuff is getting to be a little too much. If I forget to document the "barriers to learning" or some silly little thing, I just smile at my boss and go on. I take the best possible care I can of my patients, and document what I need. I doubt I will ever get hauled into court for not documenting "barriers to learning" but you can be damn sure I will be in court if I failed to document if I notified a doctor of someone going down the tubes....it is a matter of priority. Duh!!
  6. by   Kayzee
    Why is it that they expect a nurse to be flawless. You only have so much time, and yet......geez, lets not forget a thing. REALLY.
  7. by   Furball
    Are you students reading this? Not only must you be superhuman but you must document your superhumaness flawlessly....no wonder peple flee.
  8. by   ShandyLynnRN
    I hate all the paper work that has to be done!!! I realize that a lot of it has to do with Hippa, or accrediting agencies and such, but really, it takes so much of our time, and patients money, to keep up with all that stuff, not to mention all the extra jobs and time involved into checking up on us!!! I wish we could go back to just plain caring for people without having to worry about documenting!!! I know it will never get any better esp since we all seem to be accruing new paperwork instead of condensing... so sad
  9. by   VivaLasViejas
    I sympathize with you all.....one piece of advice though, NEVER work for a young company---they're never satisfied with their forms, and they change them (or add to them) every time you turn around. The last place I worked, there was no issue so complex that it couldn't be made even more so by throwing more paperwork at it. I guess they figured if three pieces of charting were good, six would be even better. Of course, the more papers they added, the bigger the chances that a nurse would forget to document somewhere, which was one of the reasons I was fired from that job. For example, when I changed so much as one item in a resident's care plan, I had to put it on the resident status sheet, the ADL sheet, the restorative sheet, the 24-hour report, the level of care report, and the care plan itself, PLUS make an entry in the nurses' notes. Multiply that by 35-40 residents, including a sizable number of skilled patients with all the changes they go through in a typical 30-day stay, and you get an idea of how overwhelming it all can be. And they wonder why they can't get care managers to stay longer than a few months........but that's another thread!
  10. by   Tweety
    I used to do chart audits (and still am supposed to, but I don't much) and 100% of the charts I audit has some omission or two.

    I figure if they didn't kill the patient they are doing o.k. Don't feel bad.
  11. by   canoehead
    Remember that all the quality review is done on the paperwork, almost none of it is done on the actual care. You are concentrating on the quality care you GAVE which is best, they just want to have the appearance of quality.
  12. by   psychonurse
    I have found in the area that I am in that documentation can save your a-- more times than you can shake a stick. When an inmate decides to sue you and get some money from the state or insurance companies or whatever it is usually at least a year from the time that the occurance happens and sometimes more. Most times I have thanked God that I charted well cause it saved me. By reading my nurses notes I could remember what happened and it gave me a nudge to know what all came about on that day. I have another trial coming up in January and I have to get the notes so that I know what is going on. So far we only have one place to do all the charting but I am sure that things will change in our area of nursing also some time in the near future.
  13. by   BadBird
    When I had to do chart audits and I found a error, I would just let the nurse know so he/she could fix it. I don't see why we have to kill each other, isn't the point of a audit to catch mistakes, so let the nurse fix them, don't crucify the nurses !!! Of course, every chart I audited was perfect since I did not play managements game.
  14. by   mattsmom81
    We're damned if we do and damned if we don't...if we stay OT to finish the ******* endless paperwork we are blasted. If we don't do all the ******* paperwork, or don't do it right, we are blasted again.

    BIG sigh.

close