Recently several staff members in our dialysis unit are initiating treatments and are delaying documentation of the 5 initial Cerner forms we complete at start of Tx, because they were assigned to start or take off other patients and did not want to "get behind." The forms include machine settings, patient vitals, vascular sssessments, pre- assessments, etc.. The forms only require 1 to 2 minutes to complete at most. As charge nurse I feel extremely uncomfortable that this documentation is not completed when the treatment begins, for numerous safety & legal reasons. I have talked to our manager who feels that some time delay in charting is O. K. at times in this situation in order to keep to the schedule. Wondering if this is done in other units and what opinions are on this practise?
I agree with you, if I am reading this correctly they are taking someone else off then going back and filling in pre assessment, eq settings, I would venture to guess that probably 60-80% of it is not getting done just getting pencil whipped. how can you do a pre assessment after the treatment is intiated? don't know what state your in but if auditors see that they will crucify you.
Thanks for feedback - I am not making any "friends" by voicing my concerns, as staff & some management are more concerned with the schedule. I plan to do an A3 problem plan.. Wish me luck. In addition to patient assessments pre & after initial start of treatment we also enter in machine readings etc., so there is no documentation that these were done at start of treatment, until patients have been "on" for 10 to 30 minutes depending on when staff have time to document. Again with the forms we have it takes less than 2 minutes to document.
good luck, stick to your principles, it's not always easy but what is right is right. Also don't put your license at risk cuz someone else is basically falisifying documents. I'll keep my fingers crossed for ya!
Thank you for your forum post. I did some treatment documentation before in my nursing career. In fact, when I worked at the skilled nursing facility, one of the ladies who was moving away showed me how to do the flowchart and also my supervisor which was the nurse on the floor and the director of the adult day care center. After the lady left and moved away, I started to do the flowchart and treatment plans. It was a bit scary at first, but once I got used to it, I thought that it was really fun to do and the patients really enjoyed having me assess them and I enjoyed documenting into the flowchart. Thank you.
It seems that documentation has changed over the course of time. I can remember learning how to document using paper-based medical records. Now, the medical records are mostly computer-based, but some of the units still do computerized and paper-based in the same unit. Most of the charting and documenting by computer are generally in the ER and CCU units which are both critical care units.
I agree in that there needed to be a treatment plan ready and in place when the treatment occurred. Treatment plans need to be in place even before treatment is beginning. There should be a care plan of action even before the patient goes in for any treatment or for any procedure. I can remember doing those care plans and flowcharts of treatment and it is always interesting to see how things are changing to more technical and are becoming more computerized. I think that it is wise to have a care plan ready to go at all times.
Treatment documentation is so important for so many reasons: 1. It allows patients, doctors, and nurses to have a good documentation record. 2. Allowing nursing students to practice their treatment documentations are very important. 3. Having some research available for the treatment plan is crucial as well. There are lots of information on renal and here is something on that:
Documentation has come a long way since I was in nursing school. I can remember my first nursing rotation. I went to the Labor and Delivery Unit and they had charts that were consistent of paper and I had to pull them out and make sure that I filed them in alphabetical order. Now, at least 98% of the charting is done by computer which is a huge help because all of the patients should be in the computer system; all the nurse has to do is to click on the link of the patient's name and then the nurse see's all of their information. What is nice is the fact that all of the information is at your fingertips. Also, you can get good flow charts and patient care plans templates which are helpful on the computer as well.