So, yeah, I'm a little AR. You know, anal-retentive? Which I think is a good thing in a nurse, right? Better than lasseiz-faire nurse ("just put that stool sample anywhere"). I am totally AR when it comes to charting, partly because of CYA (cover yer ass!) but also because I like having all the holes filled in. It just looks better when everything is in place. The charting we use where I work is a grid system, kind of like what an Excel page looks like. Pages are based on body systems, and there are a lot of add-in variables depending on what is going on with the patient (fluids, drains, skin problems/incisions, etc.). If there isn't a pre-made option, you can always create your own. The individual boxes are small and designed for 1-2 word descriptions (yes/no, wound type=incision, NS@ 100/hr, etc.), but you can comment on any box and explain yourself ad infinitum. Vital signs are fed into the system automatically, all that needs to be done is to click on the numbers to agree. I&Os are similarly quick to chart. The best part is that once you have saved your entries, the next time you click on that box your last saved entry pops up- if there are no changes you can just click "enter" to agree and shazam! Assessment charted. Which is why I don't understand why some nurses can't be bothered to chart.
Recently I got report from a day nurse who specifically mentioned several things that had happened over the course of the day. Nothing too exciting, but all things that were included in the orders as needing to be done. She goes home, I get started and log on the computer, pull up the chart and it's practically blank. Vital signs are mostly filled in (remember these are automatic), and I believe she had initial assessments charted, but other than that... what was she doing all day? Internet shopping? Helping with a code? So busy proving care she didn't have time to chart it?
We have charting guidelines we are expected to follow. Many are set by JHACO, the hospital accreditation board, some are facility guidelines, some are unit guidelines. In the ICU, our minimum vital sign charting parameter is every 2 hours, although almost everyone takes VS every hour as that is the default parameter for our monitors. Temps are taken every 4 hours (this is usually not automatic and is more frequently missed). We are expected to chart a full assessment every shift and update that assessment with any changes. We are also expected to provide personal care for our patients, feed them, turn them, ambulate them, and measure I&O down to the last milliliter. This is what nursing care is all about. Maybe this nurse did these things, maybe she didn't, but the saying around here (and probably every hospital) is "if it's not charted, it wasn't done." Two years down the road when the kids decide to sue because it wasn't grampa's time, there's going to be a chart review, and eventually someone will look at your shift and see your 12 hours basically unaccounted for. And in the unlikely event that you end up on the stand to defend your actions, you can try to tell the jury that you turned grampa every 2 hours like you're supposed to (if you even remember that night, let alone that guy), but the fact that you didn't write it down is going to make your statements about that and pretty much anything else you did or didn't do seem questionable. C. Y. A.
As an aside to the fellas, if I've not made this clear enough already, my charted assessment is very thorough, which is why I'm always over at the damn computer typing away (not, I repeat, NOT because I'm cruising Craigslist looking for secondhand toys for my kids. Or blogging.). One of the little boxes I'm filling in once a shift is "meatus assessment." That's right boys, I'm charting about your dick. Please, please don't give me a reason to go on ad infinitum.
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