Nurses frequently complain that they spend more time charting than they do caring for patients. And, they’re sometimes right but it doesn’t have to be that way. Patient care is important but so is the documentation of that care. Why? Patient documentation is crucial to discover assessment trends, determine patients’ responses to treatments, and documentation provides a means for reimbursement. Documentation also protects nurses when bad things happen to patients (will blog about that later!!). However, it can be frustrating when you have to choose documentation over “caring” for your patient.
Follow these simple tips to get more time with patients.
Chart your first assessment immediately. Your first assessment is typically the most time-consuming documentation. Getting it out of the way early in your shift allows you focus the rest of your shift on actual patient care and the crises that almost always pop up (why do neuro patients always seem to have a change in neurological assessment right before the end of my shift??!!).
Chart in your patient’s room. This is my very best advice. Bring your computer on wheels or your paper documentation into your patient’s room to complete your charting. This is a great time saver and a patient satisfaction technique. Your patient perceives that you are spending more time with them, you get your charting done and you can further assess your patient for all the little things that we sometimes forget (which arm was his IV? When was her last bowel movement, etc.)
Keep a small notebook with you at all times. Having a place to document “on the spot” can save you a lot of time later when trying to remember things once you finally get a chance to document. Things such as, what time you called the doctor, what time the patient came up from the PACU, when you suctioned him or her. Trust me, you won’t be able to rely on your memory and it could make a big difference especially from a legal perspective.
The point is this: You have to accept that documentation is an expectation and an important part of being a nurse. Complaining about it, avoiding it, or even ignoring it completely isn’t the answer or the smart thing to do. Effective charting is a skill that can be learned – just like the flow of blood through the heart.
Successful nurses learn to master charting!
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Thanks for choosing to become a nurse. I’m cheering for your success!
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