Sunday, November 25, 2012

You pay for CYA

I was about three hours late getting off work Tuesday morning, making an almost 16 hour shift. There wasn't a lunch break either. I did eat, but I had too much to do to clock out, so I ate while I charted. I try to avoid doing that whenever possible, but that night I knew that a real lunch break would only further delay my eventual exit.

 It was not a crazy night. I think I even took two bathroom breaks! My patients were not super critical, but one of them was a new admission to the hospital, and there is a ton of paperwork and documentation that goes along with that process.  I don’t mind getting out late if I feel like I contributed to something meaningful, like taking the extra time to walk a lost customer to the right unit, or shampooing a little old lady’s hair, or bonding with a non-crazy family. But I’m usually late because of charting. Stupid [electronic] paperwork.  When three or five or six things are demanded of you at once, documentation is the easiest thing to do later. I mean, really, you can’t ignore a ventilator alarm to write a note about your patient’s rash.  So I often stay an extra hour or two to chart after the next shift has taken over.

The frustrating thing about charting is that it consumes HOURS of my shift, and very little—if any—of what a nurse documents is ever actually read. 

I hate but do not regret spending that time on the chart. For every patient, every shift, you must document as if you will be on the stand in court, three years after you've forgotten the situation in question, and defending your actions as a licensed health care professional.  Every detail you note could matter later.  An excellent, experienced  nurse could do the right thing, but a failure to document why and what she did could cost her her license down the road. You never know which patient may have a complication later in his stay which calls the care providers into question. 

A typical ICU scene.
No, I didn't take this picture at work. HIPAA, back off.
You can’t (or shouldn't) rush charting. Many nurses do cut corners, but even a mistake for something insignificant could damage your credibility in court. Was that IV on the right or left arm? It’s no big deal in itself. But if you mis-document there, a prosecutor could argue that you weren't paying attention in general and similarly missed such-and-such important thing.  It’s even been recommended that nurses not talk about their late night drinking or clubbing etc. in social media. Did you brag on Facebook about staying out ‘till 3am? Did a critical incident occur on your shift the next day? You’d be surprised what could be used as an attack on your responsibility.

I try to chart meticulously because of possibilities like that. The usual reality, however, is that your pages upon pages of notes will never be looked at.  The hematologist visited my patient Tuesday morning. Did he bother scrolling through a complicated computer program to read my notes? No. Why should he, when I can verbally update him on the pertinent information in about 3 minutes? Your charting is only scrutinized when something goes unexpectedly wrong, and hospital admin puts you on the chopping block.

The sad thing is that those hours of charting could be used to give better patient care
It is absurd that a nurse who is tight on time feels pressured between:

1. changing a central line dressing (which could prevent a lethal infection) 
2. charting a note which might (but probably never) turn up in court. 

This is a deeply frustrating issue for nurses, but it should concern everyone because everyone is a potential patient.  

If you are hospitalized, your care is jeopardized by this litigation-happy system. The evidence of hands-on, proficient nursing care is evaporative compared to what is documented hard and fast in the chart. Several years after a hospital visit, a chart is often the only tangible evidence remaining. The first thing they drill into you at nursing school is that “If it isn’t charted, it was not done.”  It is sad but true.  The system rewards documentation over actual nursing care. When nurses can spend more time caring at the bedside instead of covering ass at the computer, everyone will benefit.

And I chose nursing to avoid an office job. 

Oh the irony.


  1. I'm frustrated just reading about it. Never thought about the charting being equal to CYA.

  2. Sounds like the RA dilemma times 100