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Charting Vs. Patient Care

Charting Vs. Patient Care

Brittney Wilson | The Nerdy Nurse

Teresa Brown, R.N. wrote an article, featured in The New York Times, recently called, Caring for the Chart of the Patient, in which she discusses the very real challenge we face as nurses to document our care. She speaks about the mandates, and standards that we are forced to document on in order to satisfy one agency, insurance company, regulation, or another.

What she mentions that most impacted me is that she fears that nurses are going to get to the point that unless a drop down box asked you if you did it, then you won’t. I tend to agree that this is a trend I see developing.

The panic I see in my coworkers when they are feverishly attempting to “Get the Red off” (as it is so dearly referred to because late tasks appear in red), often causes more stress and anxiety than actual patient care. In fact, patient care is almost a relief from the labors involved in charting. An admission assessment, one of the most thorough and therefore most time consuming pieces of documentation, is dreaded so deeply that nurses can become downright nasty when faced with the prospect of doing them.

She suggest a video camera to document the things she did for her patient verses charting it. As comical as it sounds, this the only way we could ever possibly hope to document every nuance of our nursing care. It’s unfortunate to think the our healthcare system is so consumed with the possibility of getting sued or not being reimbursed that they we are taken away from providing care to our patients to care for pieces of paper, click boxes, and drop down menus.

Seems like a pretty silly trade to me.

The trend toward the elimination of narrative notes (an art-form in nursing IMHO) is quickly vanishing. It is being replaced with checks, clicks, and pre-populated fields. The budding nurse informacist in me loves this. The potential this has for data management, trending, and healthcare statistics are outstanding. However, the more boxes and checks you make a nurse complete, the less time she is going to have to actually do those things that the boxes and checks stand for. Nurses are going to start doing only what is required. It is going to happen, and in fact I already see it happening.

I seriously hope with the advances we are making in technology and with charting that much of the “red” can be consolidated, automated, or even eliminated.

If we are going to chart by exception, then it truly needs to be by exception. Unless otherwise noted, then yes, we met all your standards. Thank you [insert name of various medical chart watching agency here] we did all the things you asked, educated the patient on the pertinent information, and followed all the standards and rules set form by you. We’ll make a note if we didn’t.

Next: How to Document Your Patient Assessments >>

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