A very real conversation – when nurses chart their medical care, are they depending too much on charting and not enough on connecting with the people they care for?
Nurses Chart Too Much & Don’t Think For Themselves
Teresa Brown, R.N. wrote an article, featured in the New York Times, recently 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.
Getting Red Off the Screen Instead of Actual Patient Care
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 time-consuming, pieces of documentation is dreaded so deeply that nurses can become downright nasty when faced with the prospect of doing them.
Video Camera Instead of Nurses Chart – A Possible Solution
She suggests a video camera to document the things she did for her patient versus 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 our healthcare system is so consumed with the possibility of getting sued or not being reimbursed that they 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.
Don’t Put Too Many Checkboxes in the Nurses Chart System
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 informaticist 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.
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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.
- Well: Caring for the Chart or the Patient? (well.blogs.nytimes.com)
- If You’re Looking for Some Internet Distractions with a Nursing Twist… (thenerdynurse.com)
- Nerdy Nursing Clinical Experience (thenerdynurse.com)
- Caring for the Chart or the Patient? (nursingtrends.wordpress.com)
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