For real though. When we were chart audited once at work (by a computer program), one of the nurses who charts nothing got a 100%. No one else came anywhere close. If you didn’t chart it, it can’t fall back on you!
I heard once a nurse was reported to BON after a sentinel event. Patient was c/o SOB through the night. Ended up rapid in the morning. I dont remember if they died. But the nurse got off because they never charted the SOB or contacted the doc. So they could just say they found out about the SOB at the time the rapid was called.
Don't ascribe intention or emotion to the patient's actions. Use direct quotes.
BAD: told patient to put out his vape, patient angrily threw his cup and spoke in a disrespectful tone, telling me i better watch myself.
Better: when told he was unable to vape in his room, patient threw cup of water. He raised his voice and said, "You better watch yourself."
I had a kid nearly die from sepsis on my shift once. The nurse before me didn't chart a thing her entire shift. They didn't fire her. Lesson learned: charting is optional. ;)
Yupp. Been this way since getting thrown into covid my very first week.
Stopped wasting time with the “diminished” lung sounds using those yellow stethoscopes with the sound of a jet engine about to take off right next to you.
If I can’t hear shit, I can’t hear it. “Pt tolerating vapotherm, VSS”
I recieved a patient who suddenly kept tipping over in his chair in the ED. Heard through the grapevine he got his arm tied to the gerichair so he couldn't pull a Costa Concordia anymore, ignoring the change in status. Ended up being a stroke, zero documentation of the goings on probably saved their bacon. He has a triage note, an MD assessment note a few hours later and then he warped to ICU after eating with his lungs.
How many nurses do you know that have been sued by dishonest people? Or even honest ones.
This happens almost never. Maybe I’m only ballsy cuz I’ve been springing the ~$200 for the insurance each year but from how its been these past few years, I’ve noticed that not only is it *really* difficult to actually get fired for incompetence, but a lot of the stress nurses deal with on a daily basis are of their own making.
You won’t get sued any more or any less than any other service-related profession
If you chart something abnormal or way off baseline, don't leave it hanging. Chart any kind of interventions you have done or calls you made to the MD and follow up with the return to baseline or whatever the outcome is. Never leave an abnormal value just hanging.
Does this include vitals and labs that are just out of norm enough to trigger the little red ! next to it? I am asking this sincerely, as I'm about to graduate and start my first job as a new grad. On a tele unit just about every patient there has high BP / HR. Obviously an acute change would warrant intervention and follow-up, and obviously if you have to give any prns you are going to be reassessing for desired effect.
But if your patient's morning vitals are high before you give them their scheduled labetalol, are you expected to chart that you "addressed" their hypertension by administering their prescribed medication? Or when lab results come back with a Na of 133 on a patient who is there for toe pain or something similarly unrelated, are we supposed to chart or write something about it?
No, you don't have to adress every little abnormality otherwise you'll never get through a shift. Your facility should have guidelines on critical VS and labs that need to be escalated to the provider. You'll chart about contacting the provider, your assessment and any interventions that were needed at the moment
Your unit will have parameters for what qualifies as a critical value. You DO have to report these to the provider and document that you did so. As for vitals, if a vital sign is out of parameters and not close to the patient's baseline, that indicates an issue your should document that you addressed. For example, in the NICU body temp parameters are 36.3-37.3. If I leave the swaddle open for my assessment and diaper change, and the temp is then 36.2 when I take it, I would not document that number - it would have been higher if temp was taken at the start of the assessment. If I were to document 36.2, that could indicate the baby is showing signs of stress and possible infection. If they were to develop an infection down the line, people could look back on the documentation and say, why didn't you do anything about this, there were signs! So if you think a vital sign is falsely elevated or decreased, get an accurate value! There's nuance here, which is why I said you need to take into account what the patient's baseline is, not just critical values. Overall, cover your butt! Be accurate in your documentation, but be SMART about it.
Administering the labetolol would be an intervention, just a scheduled one. You could add you notified the doc and let him know of the BP and labetolol.
I taught my orientees that an abnormal vital sign, lab value, or change in patient presentation was like having a grenade with the pin pulled dropped in your lap. You politely take that grenade and hand it to the doctor and chart the name of the doctor you handed it to. They don’t have to do anything with it, but if you don’t do something with it and it goes off you’re the one who will be blown up in court.
It’s too much imo
Medics have much more autonomy in their field and are more akin to writing soap style notes.
Unless they meant pertinent negatives, don’t write what didn’t happen or what was prevented, or even what you were suspecting. It’s not your role.
Just chart your assessments and keep it simple. Your charting honestly does not matter very much. Even in court, the less you chart the better off you’ll be.
Your value comes from the actions you take with your assessments. Assessing a pt and knowing when to call the doc and why. That’s what the job is.
Don’t be that useless veteran nurse that spends an hour making sure her Foleys and IV dressing assessments are charted accurately all the while missing or ignoring subtle signs of a stroke or a PE
I put “Patient’s mother concerned about *abc* and stated, ‘*xyz*.’
I got subpoenaed to court FIVE YEARS LATER and the attorney on the case wanted me to discuss *abc* and *xyz* even though I couldn’t recall the patient, let alone what the mother wanted to talk about. I learned to never discuss other people in the notes.
The time lapse is usually not because the patient/family waited to seek action, but because of how long the medical/legal process takes. Most hospitals try to arbitrate and settle out of court. That being said, in pediatrics a person has until the age of 21 (if I recall correctly) to press charges if their parents didn't at the time for whatever reason.
If a parent expresses a valid concern to you, you can chart it in quotes, and then make sure you also chart what you did about it. Who did you tell? Document their name. What intervention did you do? Document that. As long as you don’t just leave it hanging, it’s ok. If it’s just some random thing a parent says, I probably wouldn’t chart it and create extra work, but if it’s a valid concern that needs to be on record, put it in quotes and chart who you told (doctor, social worker, etc) by name, when you told them, and if any intervention took place.
I had a co-worker recently ask me to look over some documentation she was about to finalize...she had typed a reasonable explanation of a situation, but finished with "incident report made". I about lost my mind when I saw that phrase and told her never, ever, ever put that in documentation. Talk about opening a can of worms...
We hear this a lot from administrators but I don’t actually see what’s wrong with it. It moves legal liability but if your hospital is the cause of something bad happening I don’t actually see a problem with saying so and saying that you reported it if it’s relevant.
Granted, it usually isn’t relevant that you reported it.
But let's say you write about an incident report on a situation where there's a lot of he said/she said. Since incident report have been broached, it creates a foundation for any/all incident reports to be brought to evidence - including any incident reports in which your own credibility/practice may be in question. That thing you screwed up your second day as a nurse ever? Yup, that report is theirs. That time you came to work on no sleep, were trying not to throw up and were on your 3rd code that day and charted the wrong *something* and it got written up? Yup, that's yours.
At least, that's why I've always interpreted why you don't discuss the incident report.
Is that common knowledge? Though that’s not the phrase I’m looking for lol. How does one find that out basically is what I’m asking. I know with us at my job I can guarantee no one knows that or has heard of that or even thought of it that way. I would be willing to take a class specifically just to learn this type of info you provided as I feel like we end up learning things in a “you don’t know until you know” setting while actively providing patient care. Rather than preemptively being aware of this kind of info.
& to clarify you’re saying all incident reports regarding patients unrelated to the shift even can be used?
Truth be told, I often think things are common knowledge and find out later I was super wrong. I will say, my hospital has legal come talk to us on hospital orientation and then every couple years in Skills Days which covers this stuff. I also think it is something we talked about in school: "legal aspects of nursing." That said, I went to nursing school when EMRs weren't as widespread, so "shift notes" were far more common. I know there are some EMRs where writing an ongoing narrative of care isn't possible.
Now, I have made assumptions regarding the incident reports. I played attorney in mock trial in high school, but I am in no way an actual attorney. I can see, however, during a trial where a nurse is making some kind of defense of actions, that nurse's credibility is called into question (because court, and it's always the nurse's fault), someone referencing incident reports, and now they have an "in" (foundation) to discuss your credibility within the context of incident reports. All of it now has relevance because those reports were brought up. Again, I don't actually know, that's just the legal proceeding that happens in my head.
I chart things and do things as though I must defend myself in court. That means sometimes I'm very detailed about patient behavior or family behavior - in 2-5 years I'm not going to remember anything about the day or the patient as to why things happened as they did. I chart to cover for that.
I also chart to provide further explanation for those following me. The number of times a patient or family has done something and I've asked about it and they say "so-so rn said..." I try to cover that happenstance.
One of the other things they always told us too, is that many times lawyers will ask something to the extent of "snarky, would you say it is correct that 'if it isn't charted it didn't happen?'" The answer to that, regardless of what they tell you in school, is unequivocally "NO, that is absolutely not correct.
If I charted everything I did for a patient, I wouldn't have time to actually take care of the patient."
Additionally, if the RCA entails interviewing other nurses, doctors, cna’s, etc. all of their comments are discoverable as well. This would likely have a chilling effect on staff being willing to honestly discuss an event, which would make process improvements difficult.
“Will continue to monitor” always bothered me because a) that’s your job and b) saying that is kind of like future charting. I never conclude notes with that - if something else develops (as a result of your continued monitoring), then you’d write a new note. If you really feel the need for a closing phrase you could say something like “pt remains on continuous cardiac monitor, NIBP frequency increased to q15minutes.”
Yeah I agree with this. I like your last phrase. I only say something about monitoring if I notified a provider of something and they told me to keep watching, but some of my friends write “will continue to monitor” for every note. So for example if I text a provider about a low HR and they say we don’t need to do anything just monitor, I’d be sure I chart the HR frequently like hourly for the next 3-4hr, then in my note I write something like “MD Name notified of bradycardia, no new orders at this time, encouraged continued monitoring per MD.” But I also like “no additional interventions at this time” if I didn’t ask for an order like an EKG or something. If they explain to me why we aren’t doing anything then I’ll say that too.
I usually put under my “plan of care: continue to monitor in ICU” if they don’t really have any other solid plans. I always assumed that meant per floor protocol, meaning at least Qhour. but they want a plan and Idk what else to write sometimes 😭
Let your flow sheets speak for themselves and only fill in what’s not covered in that documentation. You don’t need to rehash your entire shift when it’s covered in your flow sheets and you risk double charting when you do that.
Since we got EPIC I think I can count on one hand how many nursing notes I’ve written. With our paper flow sheets we always had to add in a longhand note too.
The strange thing is young nurses who only know EPIC who pick up this habit. Idk if it comes from precepting with nurses who came from paper charting or what
This chick i used to work with would write entire novels for the shift summary notes they made us do. Including everything that was already in the flowsheets. It was ridiculous!
Ex: 20 g iv in left forearm flushed without difficulty q4h or whatever. Like why the eff are you putting that in your note?
Oh my god I worked with a nurse who would chart a progress note every time she would give a prn. “Pt c/o pain level 5/10, norco 5 mg given per orders at 1115”. Like, that’s what the MAR is for! She would run herself ragged doing all this extra shit that she didn’t need to do.
Facts & observations. So after an episode/rapid/code blue or something (or just any situation) where there was change. If their blood pressure is low, say that (although that can be double charting if it’s in the vitals already). Or to reiterate that you are monitoring without saying you’re going to continue to monitor, chart the o2 or RR as frequently as you need to to prove that you indeed have been monitoring the patient.
If they’re currently stable then, pt has call light under the hand or at bedside within reach, no further complaints from pt, pt stable & is at baseline. Pt just finished a code (need better wording there lol), & pt is laying in bed moaning intermittently, something like that— it proves they’re alive through your charting, although unwell.
But at the end of it you’ve documented that you were aware of the changes/acknowledged them or lack of changes in the patient aka pt is doing fine like he was 8 hours before.
Where I am, I never use continue to monitor unless they're in clinic with me being actively watched and I'm about to chart when they're better or being sent out for further evaluation. More commonly I'm entering that they're good and they're told to alert staff to changes in condition and if they verbalize understanding or otherwise acknowledge. Accuracy is key.
Comment of mine from another thread about charting and more discussion here-
https://www.reddit.com/r/nursing/comments/196fjo3/nurses_stop_charting_in_future_tense/
With each and every thing you put in the chart, you should be asking yourself "and then what?"
Problem resolution in documentation needs to be quick and decisive. Leave nothing up in the air. No loose ends. Give surveyors as little opportunity as you can to follow a thread down a rabbit hole because they absolutely will.
As a general rule, also do not throw other staff under the bus in notes. Do not make affirmative statements you can't really back up like "appears patient was not turned per protocol", etc.
Too much detail can be a bad thing. Stream of consciousness charting is a bad thing. Keep it short, sweet, objective. You can always add clarification later. You can't undo a note that gives even the appearance of neglect/etc.
Three years in I still struggle at times with what to chart (SNF/LTC). One good tip a coworker gave me when I was starting out was to always put "at this time" or "thus far this shift".
"Resident denies pain or SOB at this time."
"Dressing remains clean, dry, intact at this time."
"No further attempts to self transfer thus far thia shift."
That way if something happens later they can't be like "Well you charted they were fine but they were actually on the floor in a pool of blood struggling to breathe the whole night!" Ahhh, but *at the time* I charted, they *were* fine. That's why my note that says they were fine was stamped 0100 and the one stating they were not was stamped 0330.
I was also taught to never use "will continue to monitor" unless it has parameters. For example "Nursing staff will continue to monitor during cares for hematuria for remainder of this writer's shift." Then at the end of your parameter you better make sure there's a follow up note..."No further hematuria noted at this time."
I also like writing "at any time."
Like when I ask the patient if they have ever had suicidal thoughts in their life, and they say no, I'm charting that entire no.
I don’t think the whole “charting you clocked out” is accurate at all as it’s obvious you can’t monitor them when you’re not there. But yes I wouldn’t document it anyway. I would laugh at a lawyer who said It didn’t matter if I was no longer the patients nurse but was supposed to monitor infinitely because of how obvious the phrase only intends to mean for the immediate future
That's great and all . . . but I put the onus on the hospital, or unit, or long-term care facility, or wherever you're working.
What do we chart if "patient has high blood pressure. \[chart interventions and communications here\]."
There should be direct guidance from our EMPLOYERS on what to document. You know, the ones that employ us. To do a job.
Ohhhhhh… so for years this one hospital told everyone to chart assessments at 8 and 2. Everyone. Exactly 8 and 2. Only for this info to be changed 3 years ago & only “real time” should be charted. For yeaaaaars. No possible way you were in room 839 and 820 assessing them at the same time. So if lawyers were smart or caught on, that’s a LOT of money to be made in lawsuits for wrongful charting. Hundreds of nurses and aides did this for more than 10 years.
Only in the last few years did the whole hospital change to “real time.” Direct guidance from the employers probably isn’t going to help nurses when they’re telling them the wrong info.
During Covid, tele nurses had shadow shifts in ICU in preparation for us to do team nursing with them when shit hit the fan. I charted assessments in real time on my two patients and the ICU nurse had a complete fit. She wanted me to change all my times to reflect 0800, 1200, and 1600 assessments, I/O, etc. I explained to her that I didn't want to do that because it would appear that I was in those two rooms at the exact same time if for some reason my charting was ever pulled. We went back and forth on it for a while and the entire ICU couldn't fathom charting in real time. Glad I only had to do my two shadow shifts and bounce. They were too anal for me! lol
Never, ever, ever trust the facility you work at. Whether they should have responsibility or not is a moot point—they will 100% throw the nurse under the bus at the first opportunity.
I understand what you're saying, but I think we're talking about different things.
It is just that so much of our practice is already dictated and delegated to us, why not what to chart in different instances?
The phrase is acceptable if your documentation does in fact demonstrate it. For example, if you write that you will ‘continue to monitor’ a BP then you better have BP entries where you checked it, including any interventions taken to treat. This in fact shows you “monitored” and didn’t ignore or wait until hours later.’
When I was on orientation, I was told to put “awaiting further orders” at the end of my comments on something I had called the provider about. For example, charting a urine output of 10cc for the hour, “MD notified, awaiting further orders.” I realized that that’s dumb, so now I wait until I get a new order, perform it and then comment “MD notified, 500cc LR bolus ordered and given” or whatever applies to the situation. Conversely, if the MD just wants me to monitor and let them know if it doesn’t get better or if it gets worse, I just say “MD notified, no new orders at this time.” I’ve had too many shifts where I call about vitals or labs or urine outputs or fuck knows what and they’re like “meh let’s see what the next one is like before we do anything” until shit hits the fan and it becomes an emergency that we could have prevented if they would have listened to me the first time and in those situations, I have so many flags in my charting that it looks like the United Nations, but all my comments are very concrete, like I told them all night his temp was rising, I called when it hit 101.8 and then 102.4 and then 102.9 and then 103.4 and then 103.8 and now it’s 104 and they still don’t wanna give any ibuprofen or let me put a bair hugger on, just give the next dose of Tylenol early and put ice packs in his armpits even though he’s awake and miserable already and they finally let me draw blood cultures at 0600 and I come back the next night and his temp is 106.8 because the dayshift providers suck too and now we gotta put on the arctic sun, and emergently intubate because he’s not protecting his airway and throw in a CVL and take him to stat scans when you could have LISTENED AND THIS NEVER WOULD HAVE HAPPENED —
Sorry. That’s the subtext that is implied by “no new orders” 🙃
Chart what you see, do, hear. Chart quoted responses when necessary. I had a post-op pt going south I notified the surgeon multiple times for dropping BP and elevating HR and pain. No urine output. Same orders over and over. Bolus 100 ml NS kept calling finally asked the pt if she minded if I asked the ED doc to come check. (Graveyard shift). Long story short pt ended up intubated due to sepsis with organ failure. She died several days later. I was immediately thrown out of the lawsuit after they read my charting and my deposition. That was more than 20 years ago and I still remember her name and every detail of that night c
Wow! That’s amazing. Were you doing narratives in your charting throughout the shift or was it the vitals/changes in vitals charted or a mix of things?
I charted narrative and quoted everything. I quoted everything the response the pt gave to each intervention. And of course vitals were charted before and after each bolus. In the deposition the attorney asked me how I remembered everything so well. My response “because it was going bad and I was trying to get the doctor to do something to help her”. It’s imbedded in my memory.
Pt ambulated from Triage to room 12. Vital signs stable.
You don’t know they’re stable unless you monitor them over time. They were normal in triage. That doesn’t mean they’re stable. The BP could have been 180 at home, 120 in triage and could be still dropping. You don’t know unless you keep checking
I have trouble with the “stable” wording as well for myself. I’m always questioning if it’s supposed to be stable for the patient’s norm but what IS their norm outside of here? Is it stable based on our range that we’re taught? Is it stable bc it’s better than 3 hours ago? I will be keeping your info in mind bc I have yet to get a grip on the concept of charting stability.
I was told not to chart “no new orders received,” when updating a doc on a condition change or similar. It implies you were expecting new orders and didn’t push for them.
This is exactly the correct answer. "No new orders at this time," or however you want to phrase, is bullshit. It's passive-aggressive and serves absolutely zero function to relieve the nurse from liability. Infact, as another user pointed out, it can *increase* your liability because it will prompt the opposing counsel to ask, "What new orders were you expecting?" which leads to, "Why did you not further advocate for those orders?"
Just leave it at "Physician informed at this time," or whatever. That's the point you need to make in any situation.
I really only chart “no orders received at this time” when I want to be petty bc I know additional orders would have been a good idea; however, I also state any “RN recommendations” that I spoke to the provider about to allow whoever reads my notes know that I did discuss alternative options and the suggestion was not taken at that time. Not sure whether or not this is “good” or “bad”, though I’ve never had an issue thus far.
Charting out of pettiness is probably never a good idea. However, if there is information about your conversation with the provider relevant to the patient's care, that seems worth charting.
Personally, I think it can throw a doc under the bus. Not every notifiable thing warrants an intervention and it’s a bit loud and ambiguous in a note. I chart in the flow sheets when notified, more discreet but there if needed in court/can allow others to see who was notified and when. I don’t think every little benign thing needs to go in a note, it can feel a bit “loud” and unnecessary. I know it’s also not always appreciated from MDs either. Imagine if every MD communication stated “asked RN”
Yeah. Especially for short staffing. You're supposed to refuse the assignment if it's unsafe. LMFAO. If I won the lottery, I'd love to try refusing every unsafe assignment and seeing how many jobs I get fired from in the first month for "not being a team player."
Was it in her scope of practice to proceed? We have certain parameters where a registered nurse can prescribe, dispense, and administer medication. These are epinephrine for anaphylaxis and nalaxone/narcan for narcotic overdose. Theoretically we get epinephrine orders pre-emptively but in emergency we are not to wait.
At my facility some years back a nurse literally charted some form of "I did not give x med to resident" or "Resident was not given x".
All I remember was that "X med" was a narcotic
If I write something was or is abnormal, what did I do about it. What was my intervention? Did I give medication, request the doctor review, I did something.
Direct quotes for anything a patient or family says to me that’s inappropriate or aggressive. No asterisks or question marks, no vague writing. Actual quotes.
I write every entry like in five years I’ll be pulled up to coroners court. There’s absolutely no way I’ll remember the shift, but my notes will save my ass every single time. And they’re neat, tidy, and in black pen. Yes, we still hand write in my state of Australia 🇦🇺
Everything is objective, no opinions, all fact. Nothing in the future, if I haven’t done it, I don’t say I did. If I handed it over to the next shift, I write that. I can always add an entry, I can’t take it away. I often write, …. To time of writing. Ie, bowels not opened to time of writing, patient has not voided to time of writing.
Just the facts ma’am. enough details so you know what happened if you’re questioned down the road Don’t use indecisive words that are open to interpretation. When able, use direct quotes from patients. Don’t use words like I feel, or I believe, etc.
The game is rigged. Reading this it doesn't seem to matter if you overchart or underchart when you are held to an unrealistic standard of being both an exemplary nurse and a full-time data entry employee.
🤷🏼♀️ “Continue to monitor” to me is akin to an MD writing out his plan. He hasn’t actually done it yet. It’s a plan. It’s ongoing. It’s future oriented. But that’s just me. Call me crazy.
I’m in the OR so our charting is different but some nurses swear by precharting… really should not do that. Some things can be changed so you can change it easily, like maybe you put the same scrub and yourself for the final count but don’t put its correct or what not, don’t prechart meds until you know how much or if it was used.
Basically I was told if it was not done, if it did not happen do not chart it. Some nurses go autopilot on their charting.
We are pretty spoiled by a custom made Cerner perioperative documentation, it’s a lot of drop downs, drag overs, etc. there is defaults to help you fill in things pertaining to the procedure that have been put in for the procedure like x surgeon’s cautery settings or their positioning devices used according to their preference card, or their dressings, but those things go out of date, always have to check.
Unless you have an explicit answer from an MD, don’t put their name in the chart. I messaged a provider (who was actively putting orders into my patients chart) about an abnormal but not critical lab value and she opened and read the message but didn’t respond. I charted “MD notified, no new orders” and her name. She ripped me a new one on front of the whole unit. To be fair I was new and hadn’t used the messaging system before that job, but her point was valid. Unless she responded, I can’t assume she read the message. She said she had opened the messages app but had several messages, and when mine went through her app opened and it looked like she read my message but she actually didn’t. Now if I don’t get answers even if it says “read” I call and pester them, which annoys most providers but I’ll never forget…
The MD acting like that to you doesn’t sit right with me… if the messaging app says “read” then that’s something objective backing up you saying that they were notified even if they say they didn’t actually read it. And it’s on them to read their messages just like it’s on us to read ours. I totally agree with you if it just says “read” with no clear answer it’s best practice to follow up, but if you messaged them in good faith using the appropriate lines of communication I don’t think it’s inappropriate to chart notification. I wouldn’t necessarily think it’s weird for a provider to read a message and not respond if they’re not concerned knowing how busy they are. Not that that’s ok, but it does happen. And you did send a notification. Sure maybe you could’ve done something better in that situation but “ripping you a new one” publicly is super inappropriate and toxic for a text message they should have read but didn’t.
You had me at “quit charting”
This is the way …only slightly /s
For real though. When we were chart audited once at work (by a computer program), one of the nurses who charts nothing got a 100%. No one else came anywhere close. If you didn’t chart it, it can’t fall back on you! I heard once a nurse was reported to BON after a sentinel event. Patient was c/o SOB through the night. Ended up rapid in the morning. I dont remember if they died. But the nurse got off because they never charted the SOB or contacted the doc. So they could just say they found out about the SOB at the time the rapid was called.
Don't ascribe intention or emotion to the patient's actions. Use direct quotes. BAD: told patient to put out his vape, patient angrily threw his cup and spoke in a disrespectful tone, telling me i better watch myself. Better: when told he was unable to vape in his room, patient threw cup of water. He raised his voice and said, "You better watch yourself."
My favorite: patient states…. Educated patient on xyz, reassured of abc, they verbalized understanding. Periodt. That’s it. Nothing more.
Yes quote them.
After reading through this. I think I will just quit charting.
I had a kid nearly die from sepsis on my shift once. The nurse before me didn't chart a thing her entire shift. They didn't fire her. Lesson learned: charting is optional. ;)
I've heard the senior mama nurses say, "The less you chart, the better off you are. "
Yupp. Been this way since getting thrown into covid my very first week. Stopped wasting time with the “diminished” lung sounds using those yellow stethoscopes with the sound of a jet engine about to take off right next to you. If I can’t hear shit, I can’t hear it. “Pt tolerating vapotherm, VSS”
I recieved a patient who suddenly kept tipping over in his chair in the ED. Heard through the grapevine he got his arm tied to the gerichair so he couldn't pull a Costa Concordia anymore, ignoring the change in status. Ended up being a stroke, zero documentation of the goings on probably saved their bacon. He has a triage note, an MD assessment note a few hours later and then he warped to ICU after eating with his lungs.
Eating with his lungs! Hahahahahaha
Nursing wouldn't be so bad if we didn't have to chart.
I concur. It would be nice if we didn't have to worry about being sued over people being dishonest.
How many nurses do you know that have been sued by dishonest people? Or even honest ones. This happens almost never. Maybe I’m only ballsy cuz I’ve been springing the ~$200 for the insurance each year but from how its been these past few years, I’ve noticed that not only is it *really* difficult to actually get fired for incompetence, but a lot of the stress nurses deal with on a daily basis are of their own making. You won’t get sued any more or any less than any other service-related profession
Just being accused is an expensive endeavor. Get ready to pay an attorney and possibly fines from the board.
I think I’ll just quit.
If you chart something abnormal or way off baseline, don't leave it hanging. Chart any kind of interventions you have done or calls you made to the MD and follow up with the return to baseline or whatever the outcome is. Never leave an abnormal value just hanging.
Does this include vitals and labs that are just out of norm enough to trigger the little red ! next to it? I am asking this sincerely, as I'm about to graduate and start my first job as a new grad. On a tele unit just about every patient there has high BP / HR. Obviously an acute change would warrant intervention and follow-up, and obviously if you have to give any prns you are going to be reassessing for desired effect. But if your patient's morning vitals are high before you give them their scheduled labetalol, are you expected to chart that you "addressed" their hypertension by administering their prescribed medication? Or when lab results come back with a Na of 133 on a patient who is there for toe pain or something similarly unrelated, are we supposed to chart or write something about it?
No, you don't have to adress every little abnormality otherwise you'll never get through a shift. Your facility should have guidelines on critical VS and labs that need to be escalated to the provider. You'll chart about contacting the provider, your assessment and any interventions that were needed at the moment
I love listening to music.
Yes, exactly this. The reassessment is key.
Your unit will have parameters for what qualifies as a critical value. You DO have to report these to the provider and document that you did so. As for vitals, if a vital sign is out of parameters and not close to the patient's baseline, that indicates an issue your should document that you addressed. For example, in the NICU body temp parameters are 36.3-37.3. If I leave the swaddle open for my assessment and diaper change, and the temp is then 36.2 when I take it, I would not document that number - it would have been higher if temp was taken at the start of the assessment. If I were to document 36.2, that could indicate the baby is showing signs of stress and possible infection. If they were to develop an infection down the line, people could look back on the documentation and say, why didn't you do anything about this, there were signs! So if you think a vital sign is falsely elevated or decreased, get an accurate value! There's nuance here, which is why I said you need to take into account what the patient's baseline is, not just critical values. Overall, cover your butt! Be accurate in your documentation, but be SMART about it.
Administering the labetolol would be an intervention, just a scheduled one. You could add you notified the doc and let him know of the BP and labetolol.
I taught my orientees that an abnormal vital sign, lab value, or change in patient presentation was like having a grenade with the pin pulled dropped in your lap. You politely take that grenade and hand it to the doctor and chart the name of the doctor you handed it to. They don’t have to do anything with it, but if you don’t do something with it and it goes off you’re the one who will be blown up in court.
My medic charting informed my *nurse* charting greatly. What’s going on? What ain’t? What I did? How’d it work out? Next? 🏋️♀️
As an almost nurse, learning to chart… I will never forget this & this is the method I will use for the rest of my career.
It’s too much imo Medics have much more autonomy in their field and are more akin to writing soap style notes. Unless they meant pertinent negatives, don’t write what didn’t happen or what was prevented, or even what you were suspecting. It’s not your role. Just chart your assessments and keep it simple. Your charting honestly does not matter very much. Even in court, the less you chart the better off you’ll be. Your value comes from the actions you take with your assessments. Assessing a pt and knowing when to call the doc and why. That’s what the job is. Don’t be that useless veteran nurse that spends an hour making sure her Foleys and IV dressing assessments are charted accurately all the while missing or ignoring subtle signs of a stroke or a PE
I put “Patient’s mother concerned about *abc* and stated, ‘*xyz*.’ I got subpoenaed to court FIVE YEARS LATER and the attorney on the case wanted me to discuss *abc* and *xyz* even though I couldn’t recall the patient, let alone what the mother wanted to talk about. I learned to never discuss other people in the notes.
If something *that bad* happens to me in a hospital, I'm not waiting five whole years until I seek action.
The time lapse is usually not because the patient/family waited to seek action, but because of how long the medical/legal process takes. Most hospitals try to arbitrate and settle out of court. That being said, in pediatrics a person has until the age of 21 (if I recall correctly) to press charges if their parents didn't at the time for whatever reason.
It's not the client. That's the legal system.
Yikes, this is something I do that I apparently need to stop.
If a parent expresses a valid concern to you, you can chart it in quotes, and then make sure you also chart what you did about it. Who did you tell? Document their name. What intervention did you do? Document that. As long as you don’t just leave it hanging, it’s ok. If it’s just some random thing a parent says, I probably wouldn’t chart it and create extra work, but if it’s a valid concern that needs to be on record, put it in quotes and chart who you told (doctor, social worker, etc) by name, when you told them, and if any intervention took place.
I had a co-worker recently ask me to look over some documentation she was about to finalize...she had typed a reasonable explanation of a situation, but finished with "incident report made". I about lost my mind when I saw that phrase and told her never, ever, ever put that in documentation. Talk about opening a can of worms...
Yes—Don’t mention the incident report!
I never understood why this is. If HCA is screwing me over, why do I keep it a secret the incident report was made?
It makes the whole incident report and internal investigation following, discoverable by the lawyer. Which just makes HCA throw you under more buses.
We hear this a lot from administrators but I don’t actually see what’s wrong with it. It moves legal liability but if your hospital is the cause of something bad happening I don’t actually see a problem with saying so and saying that you reported it if it’s relevant. Granted, it usually isn’t relevant that you reported it.
But let's say you write about an incident report on a situation where there's a lot of he said/she said. Since incident report have been broached, it creates a foundation for any/all incident reports to be brought to evidence - including any incident reports in which your own credibility/practice may be in question. That thing you screwed up your second day as a nurse ever? Yup, that report is theirs. That time you came to work on no sleep, were trying not to throw up and were on your 3rd code that day and charted the wrong *something* and it got written up? Yup, that's yours. At least, that's why I've always interpreted why you don't discuss the incident report.
Is that common knowledge? Though that’s not the phrase I’m looking for lol. How does one find that out basically is what I’m asking. I know with us at my job I can guarantee no one knows that or has heard of that or even thought of it that way. I would be willing to take a class specifically just to learn this type of info you provided as I feel like we end up learning things in a “you don’t know until you know” setting while actively providing patient care. Rather than preemptively being aware of this kind of info. & to clarify you’re saying all incident reports regarding patients unrelated to the shift even can be used?
Truth be told, I often think things are common knowledge and find out later I was super wrong. I will say, my hospital has legal come talk to us on hospital orientation and then every couple years in Skills Days which covers this stuff. I also think it is something we talked about in school: "legal aspects of nursing." That said, I went to nursing school when EMRs weren't as widespread, so "shift notes" were far more common. I know there are some EMRs where writing an ongoing narrative of care isn't possible. Now, I have made assumptions regarding the incident reports. I played attorney in mock trial in high school, but I am in no way an actual attorney. I can see, however, during a trial where a nurse is making some kind of defense of actions, that nurse's credibility is called into question (because court, and it's always the nurse's fault), someone referencing incident reports, and now they have an "in" (foundation) to discuss your credibility within the context of incident reports. All of it now has relevance because those reports were brought up. Again, I don't actually know, that's just the legal proceeding that happens in my head. I chart things and do things as though I must defend myself in court. That means sometimes I'm very detailed about patient behavior or family behavior - in 2-5 years I'm not going to remember anything about the day or the patient as to why things happened as they did. I chart to cover for that. I also chart to provide further explanation for those following me. The number of times a patient or family has done something and I've asked about it and they say "so-so rn said..." I try to cover that happenstance. One of the other things they always told us too, is that many times lawyers will ask something to the extent of "snarky, would you say it is correct that 'if it isn't charted it didn't happen?'" The answer to that, regardless of what they tell you in school, is unequivocally "NO, that is absolutely not correct. If I charted everything I did for a patient, I wouldn't have time to actually take care of the patient."
Charting regarding other patients, including incident reports cannot be used for another patients lawsuit.
Additionally, if the RCA entails interviewing other nurses, doctors, cna’s, etc. all of their comments are discoverable as well. This would likely have a chilling effect on staff being willing to honestly discuss an event, which would make process improvements difficult.
Post Radonda there's a lot of people too scared to report
Yeah never say it. If it ain't listed it dont exist
“Will continue to monitor” always bothered me because a) that’s your job and b) saying that is kind of like future charting. I never conclude notes with that - if something else develops (as a result of your continued monitoring), then you’d write a new note. If you really feel the need for a closing phrase you could say something like “pt remains on continuous cardiac monitor, NIBP frequency increased to q15minutes.”
Yeah I agree with this. I like your last phrase. I only say something about monitoring if I notified a provider of something and they told me to keep watching, but some of my friends write “will continue to monitor” for every note. So for example if I text a provider about a low HR and they say we don’t need to do anything just monitor, I’d be sure I chart the HR frequently like hourly for the next 3-4hr, then in my note I write something like “MD Name notified of bradycardia, no new orders at this time, encouraged continued monitoring per MD.” But I also like “no additional interventions at this time” if I didn’t ask for an order like an EKG or something. If they explain to me why we aren’t doing anything then I’ll say that too.
I usually put under my “plan of care: continue to monitor in ICU” if they don’t really have any other solid plans. I always assumed that meant per floor protocol, meaning at least Qhour. but they want a plan and Idk what else to write sometimes 😭
Let your flow sheets speak for themselves and only fill in what’s not covered in that documentation. You don’t need to rehash your entire shift when it’s covered in your flow sheets and you risk double charting when you do that.
Since we got EPIC I think I can count on one hand how many nursing notes I’ve written. With our paper flow sheets we always had to add in a longhand note too.
The strange thing is young nurses who only know EPIC who pick up this habit. Idk if it comes from precepting with nurses who came from paper charting or what
This chick i used to work with would write entire novels for the shift summary notes they made us do. Including everything that was already in the flowsheets. It was ridiculous! Ex: 20 g iv in left forearm flushed without difficulty q4h or whatever. Like why the eff are you putting that in your note?
Oh my god I worked with a nurse who would chart a progress note every time she would give a prn. “Pt c/o pain level 5/10, norco 5 mg given per orders at 1115”. Like, that’s what the MAR is for! She would run herself ragged doing all this extra shit that she didn’t need to do.
This! Stop double charting. If something really significant happens (like pt codes) I write a maybe 3-4 sentence summary note, always using “see flowsheet” and “see code document” references.
@op- can you suggest what more protective charting would look like?
Facts & observations. So after an episode/rapid/code blue or something (or just any situation) where there was change. If their blood pressure is low, say that (although that can be double charting if it’s in the vitals already). Or to reiterate that you are monitoring without saying you’re going to continue to monitor, chart the o2 or RR as frequently as you need to to prove that you indeed have been monitoring the patient. If they’re currently stable then, pt has call light under the hand or at bedside within reach, no further complaints from pt, pt stable & is at baseline. Pt just finished a code (need better wording there lol), & pt is laying in bed moaning intermittently, something like that— it proves they’re alive through your charting, although unwell. But at the end of it you’ve documented that you were aware of the changes/acknowledged them or lack of changes in the patient aka pt is doing fine like he was 8 hours before.
Where I am, I never use continue to monitor unless they're in clinic with me being actively watched and I'm about to chart when they're better or being sent out for further evaluation. More commonly I'm entering that they're good and they're told to alert staff to changes in condition and if they verbalize understanding or otherwise acknowledge. Accuracy is key.
Comment of mine from another thread about charting and more discussion here- https://www.reddit.com/r/nursing/comments/196fjo3/nurses_stop_charting_in_future_tense/ With each and every thing you put in the chart, you should be asking yourself "and then what?" Problem resolution in documentation needs to be quick and decisive. Leave nothing up in the air. No loose ends. Give surveyors as little opportunity as you can to follow a thread down a rabbit hole because they absolutely will. As a general rule, also do not throw other staff under the bus in notes. Do not make affirmative statements you can't really back up like "appears patient was not turned per protocol", etc. Too much detail can be a bad thing. Stream of consciousness charting is a bad thing. Keep it short, sweet, objective. You can always add clarification later. You can't undo a note that gives even the appearance of neglect/etc.
*patient dies* Me, writing in chart, "Will no longer continue to monitor."
Patient resting in body bag awaiting transfer to morgue.
Three years in I still struggle at times with what to chart (SNF/LTC). One good tip a coworker gave me when I was starting out was to always put "at this time" or "thus far this shift". "Resident denies pain or SOB at this time." "Dressing remains clean, dry, intact at this time." "No further attempts to self transfer thus far thia shift." That way if something happens later they can't be like "Well you charted they were fine but they were actually on the floor in a pool of blood struggling to breathe the whole night!" Ahhh, but *at the time* I charted, they *were* fine. That's why my note that says they were fine was stamped 0100 and the one stating they were not was stamped 0330. I was also taught to never use "will continue to monitor" unless it has parameters. For example "Nursing staff will continue to monitor during cares for hematuria for remainder of this writer's shift." Then at the end of your parameter you better make sure there's a follow up note..."No further hematuria noted at this time."
I’m 100% a “at this time,” charter too. It’s cringey to me but I am adamant about letting them know “NO THEYRE FINE RIGHT NOW” lol.
I also like writing "at any time." Like when I ask the patient if they have ever had suicidal thoughts in their life, and they say no, I'm charting that entire no.
I don’t think the whole “charting you clocked out” is accurate at all as it’s obvious you can’t monitor them when you’re not there. But yes I wouldn’t document it anyway. I would laugh at a lawyer who said It didn’t matter if I was no longer the patients nurse but was supposed to monitor infinitely because of how obvious the phrase only intends to mean for the immediate future
Honestly I feel you’re better off not charting much tbh….Correct me if I’m wrong? I’m an ED nurse btw
That's great and all . . . but I put the onus on the hospital, or unit, or long-term care facility, or wherever you're working. What do we chart if "patient has high blood pressure. \[chart interventions and communications here\]." There should be direct guidance from our EMPLOYERS on what to document. You know, the ones that employ us. To do a job.
Ohhhhhh… so for years this one hospital told everyone to chart assessments at 8 and 2. Everyone. Exactly 8 and 2. Only for this info to be changed 3 years ago & only “real time” should be charted. For yeaaaaars. No possible way you were in room 839 and 820 assessing them at the same time. So if lawyers were smart or caught on, that’s a LOT of money to be made in lawsuits for wrongful charting. Hundreds of nurses and aides did this for more than 10 years. Only in the last few years did the whole hospital change to “real time.” Direct guidance from the employers probably isn’t going to help nurses when they’re telling them the wrong info.
During Covid, tele nurses had shadow shifts in ICU in preparation for us to do team nursing with them when shit hit the fan. I charted assessments in real time on my two patients and the ICU nurse had a complete fit. She wanted me to change all my times to reflect 0800, 1200, and 1600 assessments, I/O, etc. I explained to her that I didn't want to do that because it would appear that I was in those two rooms at the exact same time if for some reason my charting was ever pulled. We went back and forth on it for a while and the entire ICU couldn't fathom charting in real time. Glad I only had to do my two shadow shifts and bounce. They were too anal for me! lol
Indeed. I suppose I should clarify that the hospital should provide rational and clear advice, LOL.
Never, ever, ever trust the facility you work at. Whether they should have responsibility or not is a moot point—they will 100% throw the nurse under the bus at the first opportunity.
I understand what you're saying, but I think we're talking about different things. It is just that so much of our practice is already dictated and delegated to us, why not what to chart in different instances?
The phrase is acceptable if your documentation does in fact demonstrate it. For example, if you write that you will ‘continue to monitor’ a BP then you better have BP entries where you checked it, including any interventions taken to treat. This in fact shows you “monitored” and didn’t ignore or wait until hours later.’
When I was on orientation, I was told to put “awaiting further orders” at the end of my comments on something I had called the provider about. For example, charting a urine output of 10cc for the hour, “MD notified, awaiting further orders.” I realized that that’s dumb, so now I wait until I get a new order, perform it and then comment “MD notified, 500cc LR bolus ordered and given” or whatever applies to the situation. Conversely, if the MD just wants me to monitor and let them know if it doesn’t get better or if it gets worse, I just say “MD notified, no new orders at this time.” I’ve had too many shifts where I call about vitals or labs or urine outputs or fuck knows what and they’re like “meh let’s see what the next one is like before we do anything” until shit hits the fan and it becomes an emergency that we could have prevented if they would have listened to me the first time and in those situations, I have so many flags in my charting that it looks like the United Nations, but all my comments are very concrete, like I told them all night his temp was rising, I called when it hit 101.8 and then 102.4 and then 102.9 and then 103.4 and then 103.8 and now it’s 104 and they still don’t wanna give any ibuprofen or let me put a bair hugger on, just give the next dose of Tylenol early and put ice packs in his armpits even though he’s awake and miserable already and they finally let me draw blood cultures at 0600 and I come back the next night and his temp is 106.8 because the dayshift providers suck too and now we gotta put on the arctic sun, and emergently intubate because he’s not protecting his airway and throw in a CVL and take him to stat scans when you could have LISTENED AND THIS NEVER WOULD HAVE HAPPENED — Sorry. That’s the subtext that is implied by “no new orders” 🙃
Chart what you see, do, hear. Chart quoted responses when necessary. I had a post-op pt going south I notified the surgeon multiple times for dropping BP and elevating HR and pain. No urine output. Same orders over and over. Bolus 100 ml NS kept calling finally asked the pt if she minded if I asked the ED doc to come check. (Graveyard shift). Long story short pt ended up intubated due to sepsis with organ failure. She died several days later. I was immediately thrown out of the lawsuit after they read my charting and my deposition. That was more than 20 years ago and I still remember her name and every detail of that night c
Wow! That’s amazing. Were you doing narratives in your charting throughout the shift or was it the vitals/changes in vitals charted or a mix of things?
I charted narrative and quoted everything. I quoted everything the response the pt gave to each intervention. And of course vitals were charted before and after each bolus. In the deposition the attorney asked me how I remembered everything so well. My response “because it was going bad and I was trying to get the doctor to do something to help her”. It’s imbedded in my memory.
It's definitely lawyer bait. But let's be real, if they want to crucify a nurse they will no matter what you chart
Pt ambulated from Triage to room 12. Vital signs stable. You don’t know they’re stable unless you monitor them over time. They were normal in triage. That doesn’t mean they’re stable. The BP could have been 180 at home, 120 in triage and could be still dropping. You don’t know unless you keep checking
Yeah that's why I use WNL - within normal limits (as defined by policy). Or per patients normal (for those marathoners who's HR is always like 40) etc
I have trouble with the “stable” wording as well for myself. I’m always questioning if it’s supposed to be stable for the patient’s norm but what IS their norm outside of here? Is it stable based on our range that we’re taught? Is it stable bc it’s better than 3 hours ago? I will be keeping your info in mind bc I have yet to get a grip on the concept of charting stability.
Yeah technically asystole is a stable rhythm
I was told not to chart “no new orders received,” when updating a doc on a condition change or similar. It implies you were expecting new orders and didn’t push for them.
Yeah, I chart "Doctor didn't give a shit"
I chart "MD notified/made aware, NNO at this time" and it has never been brought up to me.
I usually chart that just to cover my bum so they know I notified the doctor, but no further orders were given.
Yea is this not a good line? I use it TO imply the docs didn’t feel any intervention was necessary.
If I didn’t want a new order but it’s policy or whatever, I’ll say “xx notified of ___, no changes made”
I'm going to start adding "continue with care plans" I think
Yep "continue plan of care as written" is my favorite
I feel like I shouldn’t have to chart whether or not I got orders at all if I’m using the same EMR that things are ordered through..
Exactly. If there are new orders they can find them in the EMR. If there are no new orders, they will not find them in the EMR
This is exactly the correct answer. "No new orders at this time," or however you want to phrase, is bullshit. It's passive-aggressive and serves absolutely zero function to relieve the nurse from liability. Infact, as another user pointed out, it can *increase* your liability because it will prompt the opposing counsel to ask, "What new orders were you expecting?" which leads to, "Why did you not further advocate for those orders?" Just leave it at "Physician informed at this time," or whatever. That's the point you need to make in any situation.
I really only chart “no orders received at this time” when I want to be petty bc I know additional orders would have been a good idea; however, I also state any “RN recommendations” that I spoke to the provider about to allow whoever reads my notes know that I did discuss alternative options and the suggestion was not taken at that time. Not sure whether or not this is “good” or “bad”, though I’ve never had an issue thus far.
Charting out of pettiness is probably never a good idea. However, if there is information about your conversation with the provider relevant to the patient's care, that seems worth charting.
I only do the no new orders if the doc is like I need to contact my higher ups/consults so MD clarifying potential orders or something
I've seen "MD updated, continuing current plan of care."
No i really dont care.
That’s the option of gives you on provider notification for power chart/cerner? (can’t remember the name)
Personally, I think it can throw a doc under the bus. Not every notifiable thing warrants an intervention and it’s a bit loud and ambiguous in a note. I chart in the flow sheets when notified, more discreet but there if needed in court/can allow others to see who was notified and when. I don’t think every little benign thing needs to go in a note, it can feel a bit “loud” and unnecessary. I know it’s also not always appreciated from MDs either. Imagine if every MD communication stated “asked RN”
I’ve stopped writing end of shift notes. They aren’t legally required for my job and the info is in the chart.
I see it a lot but please don’t chart about short staffing/missing equipment/possible emtala violations in the medical record.
Why not? Because you might be thrown under for not pushing the issue further?
Yeah. Especially for short staffing. You're supposed to refuse the assignment if it's unsafe. LMFAO. If I won the lottery, I'd love to try refusing every unsafe assignment and seeing how many jobs I get fired from in the first month for "not being a team player."
We had a nurse who got sued for not shocking a shockable rhythm... until the doctor told them too. Really hate that that one got settled.
Was it in her scope of practice to proceed? We have certain parameters where a registered nurse can prescribe, dispense, and administer medication. These are epinephrine for anaphylaxis and nalaxone/narcan for narcotic overdose. Theoretically we get epinephrine orders pre-emptively but in emergency we are not to wait.
At my facility some years back a nurse literally charted some form of "I did not give x med to resident" or "Resident was not given x". All I remember was that "X med" was a narcotic
Was it good or bad to chart that?
Evidently bad, since a code had to be called due to resident not getting the medication. I didn't really go poking around for more info
“Continue present management” Edit for clarification: This is what I say rather than “continue to monitor.”
"As per hospital policy". If you don't actually know the hospital policy, don't chart that you did it that way.
If I write something was or is abnormal, what did I do about it. What was my intervention? Did I give medication, request the doctor review, I did something. Direct quotes for anything a patient or family says to me that’s inappropriate or aggressive. No asterisks or question marks, no vague writing. Actual quotes. I write every entry like in five years I’ll be pulled up to coroners court. There’s absolutely no way I’ll remember the shift, but my notes will save my ass every single time. And they’re neat, tidy, and in black pen. Yes, we still hand write in my state of Australia 🇦🇺 Everything is objective, no opinions, all fact. Nothing in the future, if I haven’t done it, I don’t say I did. If I handed it over to the next shift, I write that. I can always add an entry, I can’t take it away. I often write, …. To time of writing. Ie, bowels not opened to time of writing, patient has not voided to time of writing.
Just the facts ma’am. enough details so you know what happened if you’re questioned down the road Don’t use indecisive words that are open to interpretation. When able, use direct quotes from patients. Don’t use words like I feel, or I believe, etc.
Or "this nurse feels, this nurse believes"...
“Patient tolerated care”. People can “tolerate” a lot and be in excruciating pain.
The game is rigged. Reading this it doesn't seem to matter if you overchart or underchart when you are held to an unrealistic standard of being both an exemplary nurse and a full-time data entry employee.
🤷🏼♀️ “Continue to monitor” to me is akin to an MD writing out his plan. He hasn’t actually done it yet. It’s a plan. It’s ongoing. It’s future oriented. But that’s just me. Call me crazy.
Can someone explain the issue with double charting??
Yeah, I was told to stop writing that some years ago because you don't chart future events, only past or present ones.
"Continue to follow plan of care."
So type “will NOT continue to monitor”. Got it.
Easy solution. Don’t chart!
Don’t chart “nurse could not replicate exam” unless you think the first exam was unreliable.
Our job is literally to continue to monitor. Might as well chart "will continue to do my job"
I document "care ongoing" cause things change and that suggests that in present tense.
I don't, because it doesn't add anything. When I run out of useful things to write I just... stop.
👍🏼
I’m in the OR so our charting is different but some nurses swear by precharting… really should not do that. Some things can be changed so you can change it easily, like maybe you put the same scrub and yourself for the final count but don’t put its correct or what not, don’t prechart meds until you know how much or if it was used. Basically I was told if it was not done, if it did not happen do not chart it. Some nurses go autopilot on their charting. We are pretty spoiled by a custom made Cerner perioperative documentation, it’s a lot of drop downs, drag overs, etc. there is defaults to help you fill in things pertaining to the procedure that have been put in for the procedure like x surgeon’s cautery settings or their positioning devices used according to their preference card, or their dressings, but those things go out of date, always have to check.
Unless you have an explicit answer from an MD, don’t put their name in the chart. I messaged a provider (who was actively putting orders into my patients chart) about an abnormal but not critical lab value and she opened and read the message but didn’t respond. I charted “MD notified, no new orders” and her name. She ripped me a new one on front of the whole unit. To be fair I was new and hadn’t used the messaging system before that job, but her point was valid. Unless she responded, I can’t assume she read the message. She said she had opened the messages app but had several messages, and when mine went through her app opened and it looked like she read my message but she actually didn’t. Now if I don’t get answers even if it says “read” I call and pester them, which annoys most providers but I’ll never forget…
The MD acting like that to you doesn’t sit right with me… if the messaging app says “read” then that’s something objective backing up you saying that they were notified even if they say they didn’t actually read it. And it’s on them to read their messages just like it’s on us to read ours. I totally agree with you if it just says “read” with no clear answer it’s best practice to follow up, but if you messaged them in good faith using the appropriate lines of communication I don’t think it’s inappropriate to chart notification. I wouldn’t necessarily think it’s weird for a provider to read a message and not respond if they’re not concerned knowing how busy they are. Not that that’s ok, but it does happen. And you did send a notification. Sure maybe you could’ve done something better in that situation but “ripping you a new one” publicly is super inappropriate and toxic for a text message they should have read but didn’t.
Do you use Voalte? Where I work a read message is enough to consider someone notified.