July 4, 2018

Real-Time Charting | Nursing Hacks # 6

A year and some change ago, I precepted and trained my girl, Ashley. She is now my co-host on The Working Nurse Podcast (click here to listen). After training, our friendship grew, and I now consider her one of my best friends. Back then (during training - the first two weeks), Ashley and I would get into tiffs over her charting. She would do this thing where she would perform tasks and then afterward, sit down and "catch up" on her charting. That was a pet peeve of mine, and one day we sat down and I explained why.

Charting is to be done in real-time, and most facilities require nursing staff to chart in this manner. When Ashley would perform her assessments, I would have her chart the entire evaluation while in the room (using the room's laptop). I didn't allow her to step out, sit down and get distracted by other things (Hey, I'm not evil. I have my reasons, let me explain). At first, she was annoyed and irritated at the request. Oh, yes she would shoot me daggers while in the room, haha. But with this action, her charting was always real-time and completed right then. She never needed to "catch up" on anything. As a preceptor, this was great because I could promptly review her charting, and we could discuss any needed changes immediately. I remember being a new nurse and nothing irritated me more than the shift ending and my preceptor making me fix my charting SIX times (per mistake) because I made the same mistake each entry (ICU nurses chart assessments every two hours [where I work] - 19:00, 21:00, 23:00, 01:00, 03:00, and 05:00). If we had talked about my errors during the shift, I wouldn't have copied the same mistakes over and over again.

Ashley usually never had late entries or delays (98% of the time - come on now, nursing is still nursing. Nothing is 100%). We never had to stay late for her to "catch up" on her charting and she never had to skip lunch to chart either (now that statement is 100%. I don't stay late, EVER). The first day of training I told Ashley, "I've been a nurse for five years. I've never stayed later than 7:35 AM (for night shift) or 7:35 PM (for day shift). I will not with you, so let's sit down and let me explain my expectations." I don't stay late. And I don't allow people I train to chart or stay late either. Charting is meant to be done in real-time. When you chart late-entries, it doesn't look good. Are you going to go to jail? No, but let's think this through. For example, you're three hours behind on your charting and your patient codes and sadly, passes away. Now, you have to chart all the pre-code vital signs and assessments, the code blue event itself (along with the given medications), perform postmortem care and chart the deceased patient checklist and security forms. Charting late ONLY delays the inevitable. And as more time passes, the to-do list gets bigger and bigger. Oh, and what if the doctor (during the code blue) wants the last set of vital signs and assessment before the patient coded? Would you know that information? Would you remember it at a time of total chaos? I usually have my patient's electronic chart open during the code for this very reason. But if you have no data, you are screwed.

The more time that goes by without you charting, the more things you must chart. Don't kid yourself. Sit down and chart right then, right when the event takes place. I know, you have 100 things to do. But charting is time-stamped. So, when you chart the 19:30 assessment at 23:15 (and you change the entry time to 19:30), those actions are logged. Does it make you an evil person or a liar? Of course not, but it doesn't look good. If a lawyer looks at it, let's just say you might have some problems. Start good habits, and begin with your charting tactics. Ashley probably hated my guts when I was training her but now, she's a graduate nurse who went straight into the ICU setting, and she is flourishing. She manages to chart real-time even in the critical care chaos. And sometimes I look over, and I still see her charting in the room, haha. Now, this is advice is for new nurses but all nurses can use this one. I have even seen nurses with 20+ years of experience chart their ENTIRE SHIFT's tasks and assessments at the very end of their shift. Yeah, not good!

Listen, I'm not saying there won't be situations where your charting is delayed. What I'm saying is if you find reasons to delay things, they will pile up and be waiting for you. Documentation doesn't disappear, and it doesn't get done by your assistant. It's all on your shoulders. Be proactive and not reactive in your documentation goals.