Friday, June 6, 2014

Less is Best

"If it wasn't documented, it wasn't done."

This is ridiculous.  I wish people would stop promoting the notion that it is possible to record every little thing that the nurse does for all of her patients and that if something was not documented, it was not done and caused a patient's problem.  Most things that a nurse does for a patient are not documented because this is not practical, but this does not mean that the undocumented care was never performed.  If a hospital actually believes that every act can be recorded in the patient's chart, then they need to assign three scribes to every nurse.

Who documents every damn call light?
Folks, in medical settings, there are people who ring the call light NONSTOP.
This is extremely time-consuming.

I do rounds at the beginning of a shift and greet patients, adjust people and items, answer questions.  In my current setting, I usually have about 30 patients; in the nursing home, I had anywhere from 30 to 60 patients.  My shift is not designed for me to open 30-60 charts after my initial rounds and document the condition and services rendered to every patient.  That could take an hour.

Take a highly detailed, minute-by-minute account of a patient's care during a shift.  That nurse spent more time creating the shift notes than she did delivering actual care to patients.  Who was caring for the patient while the nurse was documenting the care already delivered?  Do we really want a nurse paying more attention and time to a chart than to the patient?

In every setting I have worked, I have also been told that "Less is Best."  The more details you provide, the more you open yourself up to criticism for doing something wrong.

For example, a blood pressure reading.  Desired at my places of employment:  BP 128/78.  End of story.  If you were to write a more detailed note, such as, "seated BP 128/78 via manual sphygmomanometer on upper right arm," someone could attack every element.  Had you measured the blood pressure standing up, you would have gotten a lower reading, perhaps indicating postural hypotension and the need to institute fall precautions.  The sphygmomanometer was found to be defective during an inspection the next day.  A review of the patient's medical history revealed a mastectomy of the right breast, so the right arm should not have been used to measure blood pressure.  BUT- If you simply record the blood pressure, you have wiggle room should an incident arise later.

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