Sunday, November 27, 2005

Charting the Course

Made it to the Notre Dame/Stanford game this weekend. I walked into the Stanford stadium thinking the Irish would grind the Cardinals into the turf, but by the time I left I would have accepted a hefty dose of IV Valium. I like my football nice and calm. A 30 point lead in the first quarter, a nice half-time show by the marching band and fluffy pom-poms to wave at the appropriate moments.

Last night was gut-wrenchingly close. Stanford played their heart out, but the Irish pulled it out in the last two minutes. It was the last game Stanford would ever play in their stadium. Right after the game, literally, they began to tear down the old stadium in preparation for what looks to be a fantastic replacement.

I could write an entire blog entry on the differences between the Stanford and Notre Dame cultures, both campus and football. Having experienced both this month, it was like visiting two different worlds.

If Stanford had been playing any other team, I would have rooted for them. But they were playing Notre Dame. 'Nuff said.


I love charting! A well-written chart is a piece of art; every entry a chapter in the book that becomes The Medical Record.

Nurse's notes are my passion. I must chart in blue and I must have a medium-point, gel-ink pen that does not scratch the page as it flows. I accept no substitutions. I carry a small, six-inch ruler so that my lines are straight.

I do not chit-chat while charting; I eschew the tantalizing temptation of socialization with my colleagues until my nursing narrative is completed to my exacting specifications. I have claimed a small corner desk as my "office", to the distress of my fellow nurses, for that is the desk they use to surf upon the internet. I daresay that my attempts to construct a medical work of art supersedes their need to (1) check their cell phone bill or (2) make bets on the NFL.

I'm not kidding!

I really do enjoy charting as part of my nursing responsibilities. A well-written nurse's note acts as a timeline of the emergency visit. I make sure mine are:
  • Legible
    • Doctors may be notorious for illegible handwriting, but I know a lot of nurses who make doctors' writing look like calligraphy.
    • If that note gets blown up poster-size to sit in front of a jury, I want my writing to reflect that I am a professional nurse, not a literary slob.
  • Complete.
    • You might be Nurse of the Year but as the old saying goes, "If you didn't chart it, you didn't do it.
    • Check every box, chart every response, write N/A where applicable to show that a topic was at least considered
And, in addition to charting my actual nursing care, I make sure to chart:
  • Times
    • Time that patient was roomed.
    • Time that the doctor evaluated the patient.
    • Times of each test (lab, radiology)
    • Times that the patient was out of the department.
    • Time of discharge
  • Consultations/Communication
    • If I hear the doctor on the phone in consultation with another physician concerning my patient, I'll verify who they were speaking with and document it on my notes with the time of the call.
    • When the EDMD goes back to the bedside to discuss the case with the patient or family, I will note that it occurred. I don't go into detail, perhaps I'll just write, "EDMD at beside, case discussed with patient and family".
    • When I update the EDMD with patient information (medication response, a change in vital signs, etc.), I document what I said and when I said it.
  • Patient comments and behavior.
    • Verbal abuse - I will chart what the patient said, verbatim, including the foul language, in quotes.
    • A threat to sue - if a patient makes a threat to sue while in the emergency department, I will quote it, again verbatim, in the record.
Of course,the goal is to document, as objectively as possible, what is happening during the patient's time in the department. The nursing record is really the only part of the medical record that gives "real time" information. It pulls together and reinforces all the other documentation, including the EDMD dictation.

I've worked with doctors who do medical-legal chart reviews. They have story upon story about how a single entry in a nurse's note stopped a lawsuit in its tracks.

Pretty impressive.

It doesn't take any more time to document thoroughly, clearly and legibly than it does to scribble what looks like incoherent mumbling on a page. It does take organization, focus and good management of your time. It isn't rocket science.

I do it every shift.

With a medium-point, blue gel-ink pen and a six-inch ruler.


At 11/28/2005 04:36:00 AM, Blogger kenju said...

Kimn, you are probably the envy of every other nurse at your hospital and doctors would no doubt kill to have you do their charts. Too bad not everyone follows your example.

At 11/28/2005 06:15:00 AM, Blogger angry doc said...

Some of the nurses I worked with were such dedicated charters, they wouldn't stop to give you a hand at the resus...

At 11/28/2005 07:37:00 AM, Anonymous Jenn said...

I did chart reviews and appeals for an insurance company for awhile, and I can't tell you how much accurate, complete, nurse's notes help.

At 11/28/2005 08:08:00 AM, Blogger Moof said...

First, I want to take a (hopefully) well aimed *SWAT* at "Angry Doc" ... --> Play nice! ;-)

Secondly, I think careful charting can save a tremendous amount of grief later. It's a shame that more medical workers don't think the way you do.

That said ... Blue pen? Medium? Liquid Ink? ... Although ... perhaps you just might enjoy is a bit *too* much ... have you had a talk with "Shrinkette" lately? 0.o

At 11/28/2005 09:14:00 AM, Blogger The Platypus said...

Computer charting has made my life a lot easier, and my handwriting a lot sloppier, but I'm amazed at how many of my peers don't bother to document the obvious,

And right on with the threats to sue. If a patient mentions the intent, whether to sue me or the hospital or whatever third party (s)he thinks will provide a stream of income, I always write that up in detail. I'm sure their attorney appreciates it when they pull the chart in preparation for court.

At 11/28/2005 12:07:00 PM, Blogger Kim said...

LOL Doc - I am the de facto scribe at all the Code 3s unless it is my patient and then I'm working the bedside.

At 11/28/2005 12:12:00 PM, Anonymous DawnCNM said...

I loved your note about charting, since it's so true from the insurance point of view (I have worked on both sides, hospital/office and insurance company). More charts like yours from doctors and nurses would make our jobs reviewing for medical necessity much easier. However...would you consider using BLACK ink instead of BLUE? Blue just does not copy or fax well for some reason.

At 11/28/2005 12:49:00 PM, Blogger Kim said...

Dawncmn, Oh no! Black ink bad! LOL!
I get anxiety attacks just thinking about black ink! LOL! Seriously, I have worked in facilities where black was required but thankfully I'm at a blue-ink ER now. I knew a doctor who wrote in purple! And got away with it! My absolutely favorite ink color is Teal, but I won't push my luck!

At 11/28/2005 04:48:00 PM, Blogger angry doc said...


But it's true! Especially just before the 2pm change of shift...

At 11/28/2005 06:41:00 PM, Blogger Third Degree Nurse said...

I love it! I am actually getting the hang of charting. Coming from the legal field, I recognize the value of medical records. You're my role model on this one: I have my six inch ruler and am ready to go. However, we must use BLACK ink in our area.

I'm DETERMINED to get my assessment done and all charting complete and accurate by 0830 tomorrow. No matter how bad the patient's diarrhea is. And today it was pretty bad.

At 11/29/2005 05:52:00 PM, Blogger Jo said...

You are an excellent role model for us students as well. I may move to CA to your facility just so I can write in Blue though. I'm jealous, Black is required here. However my pen has to be the gel type also, My hand camps with the ball-points, I write too hard with those.

At 11/29/2005 11:19:00 PM, Blogger Unimum209 said...

Oh how I long to be able to write with my blue pen... I am a fine point girl myself though. I am a SN in Australia and we are only allowed black pens.

I loved your blog on charting. I wish everyone was as concerned about getting it right as you are. I am such a newbie that I gratefully accept all the advise I can get - especially on issues like charting.

At 11/30/2005 08:55:00 AM, Anonymous Dave Harmon said...

I've got no argument with careful documentation, but, speaking as an outsider -- perhaps you could explain why black ink is so bad?

At 11/30/2005 02:54:00 PM, Blogger missbhavens said...

A ruler? Right ON! Now THAT'S taking charting seriously. Alas, we cannot chart in blue. My charting fantasy pen is a fine-point gel roller (0.5, please!) with ink as black as a labrador retriever. I think we're not allowed to use blue because we chart on pink sheets. Blue on pink doesn't xerox well, or something like that...but who xeroxes charts?

Thanks for the bloggy visit and the kind words! (I'll tell your engagement story and then maybe she'll cut me some slack!)

keep up the uber-charting! You do us proud!


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