A few months ago, I was getting my 90 day evaluation (after 2 travel contracts, then hired on FT)... I recieved a great review, then was asked to voice (vent) my thoughts, concerns...
Working here in Florida, there is this thing called "Season" where half of the north comes to Florida, many in ill health. It is the craziest work environment I have ever seen... Anyway, this review came at the end of "Season".. While quickly pondering what to say, and how to say it, this thought came to me in a flash.. With all the stress nurses have to deal with simply doing their job, then adding all this "JCAHO this" and "EMTALA that", and "Patients must be seen within 5 min of arrival, even if their tooth has hurt them for two weeks", this is the one basic "catch-all" question I had for her.. Here goes..
"If all parties involved, legal, state, federal, JHACO, EMTALA, etc., can be satisfied with an MD (who really has all the liability) using one form for each patient, why do we have a minimum of 30 min of computer work/paperwork per patient, even a well-child exam??
She really couldnt answer beyond the typical administrative answer I have heard for 14 yrs.. "We are constantly trying to minimize and streamline the paperwork and charting process"...
So, for all you nurses out there that buy the "It is JHACO mandated" and "It is a federal requirement", answer that question for me please. Why are doctors allowed to simply fill out one quick-fill form and we arent?
I could double my workload, AND improve my patient care, if it were as simple for us as it is for MD's..
In my mind, I think it is more a matter of an over-abundance of higher educated medical professionals that if not for making, imposing, reviewing, and enforcing "regulations", they would be out of work... Nothing else makes sense, because I refuse to believe that regulating bodies place more responsibility on nurses than they do MD's.... And I also believe it is because MD's do the minimum, and if held to a higher expectation, a certain finger of theirs gets held higher...
Let me do some pondering before I do anymore posting on why I might figure it is that we nurses [even military] must kill the proverbial trees during the course of patient care.
LOL, such deep questions are making my shoulder hurt.
(smile)...yes, it seems in the wonderful world of technology, we still seem to have more paperwork than ever. The paper shredder is always too full to work, the recycling bin is over loaded...and we still carry around a ton of papers. JCAHO and all those governing bodies seem to think that we have to "show" on some sort of flow sheet, check off sheet, and other signed documents that we are actually doing what we are. And now HIPPA comes in, and we can't even have all those papers we were told to have, out in the open to public view!! So now we have to keep it hidden, or turned face down, or covered up! When will it end? I feel for ya'! I can definitely relate, I am forever being told that I don't document well enough in as many places I should...but I guarantee, my patients are well taken care of. Oh well...hang in there. Ruby 43.
Our docs don't really fill out anything they dictate so all they right is seen H&P see note then talk on the phone and lots of the info they have for their dictation are those notes that we record :)
We fill out a "self eval" before our yearly eval and my thing I don't like about my job every year is the paperwork. The thing I like stays the same too...my goal well really nothing to do with nursing (or nursing at this hospital) and they don't want my yearly personal goal of losing weight which is never met.
BeachyCEN wrote:]All I can think of is, if it is not documented, it's not done...learned that in nursing school :)[/COLOR]
And A LOT of what we learned in nursing school was bunk.. Why do you even need to do complete VS on someone with a fish hook stuck in their finger and 18 yrs old with no medical hx??
Doctors all the time love to say "we may open a can of worms" when you suggest certain tests, other times they are doing LP's on 4 mo old's with a 99 deg rectal temp... No rhyme or reason in this profession anymore... I remeber the "good old" paper (pre-JHACO) days when everything you needed to document was.. i.e., the damn reason the pt was there, what you did to resolve the problem, and the outcome....
I long for those days...
How's this for "efficient": My 5 year old daughter dropped a glass on her foot and had a laceration. I brought her to the ER, was at her side the whole time. They checked her foot, stitched it up, and off we go. Totally appropriate care for the injury. Later, I get her medical record and it has a FULL physical assessment documented, heart sounds, lymph nodes, lung sounds, etc. None of this was done. I call the hospital administration and say, "listen, this is a legal document. If tomorrow something happened to my daughter, this record would be the legal truth of her condition, and care would be dictated accordingly, and this is a complete fabrication." Come to find out, the transcription service had a mechanism in which the doctor simply said "normal" for that system, and that generated a dictated note of a full "textbook normal" assessment for that system (and they all knew it.) They promised to advise the doctors to only use it if they really did the assessment...Scary!
I'll never forget the 80 year old man who came into our office and complained about his incorrect bill. We had charged him for a pelvic exam! The customer is always right, right?
Ok, started at a new hospital with McKesson system and did my first direct admit (with no supervision) - it was unreal... I now know what my patient's second cousin removed, that was married to her husband's niece, medical history. ABSURD! Concise medical history is the only thing I am looking for. A two hour intake history is way too much nursing time to spend to click on all that and really not be relevant to my patient or present concerns. Cut out the check list BS and just let me chart without having to search for the correct category to chart it in.
Talk about a dinosaur, we have reverted rather than progressed.:33:
I SAVED 3 LIVES TODAY, BUT I KILLED THIRTY TREES IN THE PROCESS.
I do agree with you though, we have to document everything we do even a simple thing like a fingerstick just to rule out that problem or another,blah, blah, blahhhh and what about all the inocent pens we slaughter for the sake of regulations?
Dr's only have to pick up a dicta-phone and talk gibberish for a moment or two then move on to the next patient.
I kind of like electronic documentation systems myself. Seen a few really good ones that cost too much; used several not-so-good ones that cost less. I don't like to write since my penmanship is terrible and while dictation saves the "dictator" time, it's difficult at best to transcribe. Have you seen the transcription error emails? What a riot! Anyway, I suppose there's no perfect system.
The electronic age is only as good as the electricity that is supplied. My mom, may she rest in peace, had her last hospitalization charted on computer, and when the computers "went down" so did all the info. No one knew if she had had a bowel movement recently, needed an enema, was due for medication, and the list goes on and on. Give me those old reliable paper charts anytime. It sounds like you all have some wild stories to tell. I came across an interesting site recently for sharing experiences and read a cute one about a super nurse. If you're interested you can read it at this link: Care2tell - A Shot in the Park
In the meantime I'm enjoying my retirement and reading all your stories. It brings back good memories.
We know the pitfalls and advantages all computerized systems bring, but keep in mind there has been a proposed governmental bill floating out there that wants all citizen's medical history concisely available in electronic form, in order "to save money"??? I cringe at the nightmares in confidentiality and technical gliches this could bring if passed. We had a guy here in FL who had a fight with his S.O. who worked for the Dept. of Health and put the names of HIV pt's he had in his possession online....He got caught, but too late for the patients.
Puts new meaning into 'Big Brother' is watching. One problem with electronic charting is possible corruption of data, I think. Some of the dictated stuff I've seen are filled with holes..... I say chart by exception.
BeachyCEN wrote:]All I can think of is, if it is not documented, it's not done...learned that in nursing school :)[/COLOR]
yes but do we have to document the same thing 3 or 4 times? for instance FSBS it prints of a paper and we put it in the lab section, we have also charted in the MAR, the nurses notes and on the 24hour report? really is all that nessecary?:( i would rather spend my time with my patient. its heartbreaking being in long term care when you can' t take the time to really see how your pt is doing by having an actual conversation
I can only imagine how frustrating this duplication of effort must be. There must be some bright "techie" out there with a solution to the problem of how to record it only once yet get it distributed to the proper destinations--Morse code?
Reneec wrote:I can only imagine how frustrating this duplication of effort must be. There must be some bright "techie" out there with a solution to the problem of how to record it only once yet get it distributed to the proper destinations--Morse code?
Ya know, I think the biggest pet peeve that I have about nursing is the insane amount of documentation that is now considered essential. I realize that these are my personal observations but I've been doing this for a long time and have seen the changes. Let's see where it comes from now... We have the bureaucratic, government driven,machine, JCAHO; morphed to out-of-control proportion in response to the bigger machine- the healthcare insurance industry. Their tactic; let's hold reimbursement hostage till you comply or my favorite- we'll send out the chart auditor to fine-tooth the record and look for any possible reason to decline payment. You can be absolutely sure they'll find one.
Then there's the less popular, paranoia driven, "I need to write everything down or else" reason for senseless documentation. I find crap like "Patient observed to be resting in bed with three rails in upright position watching television from 1400 till 1545, at which time he rang the bell to get up to void 400ml of clear yellow urine without difficulty, at the bedside, into the urinal. Patient assisted back into bed safely and rail returned to upright position". Thank you very much, Jim Sokolove, and all of your fellow bottom feeder, opportunists who use greed and entitlement to generate many pointless lawsuits.
Okay, okay, I'm off my rant now but see what I mean?
Ricu wrote:Ya know, I think the biggest pet peeve that I have about nursing is the insane amount of documentation that is now considered essential. I realize that these are my personal observations but I've been doing this for a long time and have seen the changes. Let's see where it comes from now... We have the bureaucratic, government driven,machine, JCAHO; morphed to out-of-control proportion in response to the bigger machine- the healthcare insurance industry. Their tactic; let's hold reimbursement hostage till you comply or my favorite- we'll send out the chart auditor to fine-tooth the record and look for any possible reason to decline payment. You can be absolutely sure they'll find one.
Then there's the less popular, paranoia driven, "I need to write everything down or else" reason for senseless documentation. I find crap like "Patient observed to be resting in bed with three rails in upright position watching television from 1400 till 1545, at which time he rang the bell to get up to void 400ml of clear yellow urine without difficulty, at the bedside, into the urinal. Patient assisted back into bed safely and rail returned to upright position". Thank you very much, Jim Sokolove, and all of your fellow bottom feeder, opportunists who use greed and entitlement to generate many pointless lawsuits.
Okay, okay, I'm off my rant now but see what I mean?
LivingDeadNurse wrote:hey when did you read my charting??? lol
I know. Don't you find yourself charting nearly the same things on each patient too? My favorite thing to write on our chart-by-exception flowsheet is "See electronic record" since we have to do both.
Keeping a sense of humour....warped or otherwise....really helps. I figure if I can't laugh at least once a shift, something is inherently wrong somewhere.
Maybe my attitude comes from always having done tons of charting but I would rather triple chart everything...
The way I look at it is, my professional liabilty insurance cost me less than 50 bucks a year, how much does a doctors cost?
[QUOTE=amberdouglas;62740]Maybe my attitude comes from always having done tons of charting but I would rather triple chart everything...
The way I look at it is, my professional liabilty insurance cost me less than 50 bucks a year, how much does a doctors cost?[/QUOTE
I'd rather document only what's essential than to write volumes of extraneous, nonessential fluff. Writing more does nothing to minimize your liability in fact, it can increase it. Chart auditors have a field day with endless documentation. Write only what's needed and be concise besides, who has time to waste?
Interesting discussion. It looks like you all have tons of issues with the electronic end of things.
Technology is really about process and decreasing redundant documentation. If you are working on a system that doesn't help with that, then you need to get active with your IT department to find a better solution.
Count how many times and places vitals are documented (either on paper or in an e-chart)
Count how many times meds are documented?
So much redundancy in Nursing documentation and there is tons of research showing transcribing errors in nursing documentation.
that said, every e-chart should have redundant backups....so if power goes out, there should be back up power to switch over to, as well as a back up of the database regularly......
OpensourceRN wrote:Interesting discussion. It looks like you all have tons of issues with the electronic end of things.
Technology is really about process and decreasing redundant documentation. If you are working on a system that doesn't help with that, then you need to get active with your IT department to find a better solution.
Count how many times and places vitals are documented (either on paper or in an e-chart)
Count how many times meds are documented?
So much redundancy in Nursing documentation and there is tons of research showing transcribing errors in nursing documentation.
that said, every e-chart should have redundant backups....so if power goes out, there should be back up power to switch over to, as well as a back up of the database regularly......
Sorry, TECHIE RN entered picture.........
:33::)
Good input Opensource. Thank you.
I hold no fault with electronic documentation whatsoever in fact, prefer it. Now let's look at how those systems are built. I'm currently trapped in the "staged construction" of a system being done by our own IT department. I recognize that if the hospital would've just bought the product that we will eventually end up with it would've been a lot easier and considering the fleet of IT people running 24/7 in the place, no real money was saved but spent on salaries. Simultaneous to the never ending implementation of our nursing documentation system was our electronic medication administration record. Oh, and by the way, including lab and radiology reporting,none of the systems talk to eachother. Dollar for dollar, I think it's by far smarter AND safer to spend a million dollars on a comprehensive package, do one giant installation and get it over with because this "homegrown" crap takes an eternity to complete and then there's the support of it all. What a hassle.
amberdouglas wrote:Maybe my attitude comes from always having done tons of charting but I would rather triple chart everything...
The way I look at it is, my professional liabilty insurance cost me less than 50 bucks a year, how much does a doctors cost?[/QUOTE
I'd rather document only what's essential than to write volumes of extraneous, nonessential fluff. Writing more does nothing to minimize your liability in fact, it can increase it. Chart auditors have a field day with endless documentation. Write only what's needed and be concise besides, who has time to waste?
R
I never said I chart nonessential stuff, I said I'm used to triple charting...big differance. A good friend of mine is a Joint Commision auditor, so i always get to hear about whats right and whats wrong.
As for wasting time, I consider my charting as part of what I am supposed to be doing, not time wasted, becasue it IS what i am supposed to be doing...
The last time I had a chart audited, the ONLY thing they found wrong in my charting was I and O's were not totaled up and graphed...
Ricu wrote:I never said I chart nonessential stuff, I said I'm used to triple charting...big differance. A good friend of mine is a Joint Commision auditor, so i always get to hear about whats right and whats wrong.
As for wasting time, I consider my charting as part of what I am supposed to be doing, not time wasted, becasue it IS what i am supposed to be doing...
The last time I had a chart audited, the ONLY thing they found wrong in my charting was I and O's were not totaled up and graphed...
Sorry Amber,
I didn't mean to imply anything about your personal documentation. I was generalizing. I guess I shouldn't have hit the "quote" button when I replied but your entry is what got me to thinking about all of the wordy, unessential, and sometimes misleading stuff that finds it's way into nursing notes.
I hold no fault with electronic documentation whatsoever in fact, prefer it. Now let's look at how those systems are built. I'm currently trapped in the "staged construction" of a system being done by our own IT department. I recognize that if the hospital would've just bought the product that we will eventually end up with it would've been a lot easier and considering the fleet of IT people running 24/7 in the place, no real money was saved but spent on salaries. Simultaneous to the never ending implementation of our nursing documentation system was our electronic medication administration record. Oh, and by the way, including lab and radiology reporting,none of the systems talk to eachother. Dollar for dollar, I think it's by far smarter AND safer to spend a million dollars on a comprehensive package, do one giant installation and get it over with because this "homegrown" crap takes an eternity to complete and then there's the support of it all. What a hassle.
Okay, I'm done now.
R
Ricu
Great points......Problem with IT today is that the vendors wanted to take hospitals (even for the last 20 yrs) for all their money, with very limited scoped products that were not fully baked or some that were even over baked (so many bells and whistles when all you needed were the fundamental capabilities)and you only get 5% utilization of the product because it is not user friendly and very complicated. An integrated solution makes sense for the most part, but vendors do not do "everything" perfect. Best of Suite often is a great way to move with technology.
I hold no fault with electronic documentation whatsoever in fact, prefer it. Now let's look at how those systems are built. I'm currently trapped in the "staged construction" of a system being done by our own IT department. I recognize that if the hospital would've just bought the product that we will eventually end up with it would've been a lot easier and considering the fleet of IT people running 24/7 in the place, no real money was saved but spent on salaries. Simultaneous to the never ending implementation of our nursing documentation system was our electronic medication administration record. Oh, and by the way, including lab and radiology reporting,none of the systems talk to eachother. Dollar for dollar, I think it's by far smarter AND safer to spend a million dollars on a comprehensive package, do one giant installation and get it over with because this "homegrown" crap takes an eternity to complete and then there's the support of it all. What a hassle.
Okay, I'm done now.
R
Ricu
Great points......Problem with IT today is that the vendors wanted to take hospitals (even for the last 20 yrs) for all their money, with very limited scoped products that were not fully baked or some that were even over baked (so many bells and whistles when all you needed were the fundamental capabilities)and you only get 5% utilization of the product because it is not user friendly and very complicated. An integrated solution makes sense for the most part, but vendors do not do "everything" perfect. Best of Suite often is a great way to move with technology.
There are opensource solutions already on the market to help cut the costs significantly. The challenge is that with an opensource solution, you are not going to get the Prettiest application. So you need good leaders to understand what the needs are and guide your clinicians to a solution that works and is proven and doesn't take 10 yrs to install with no user adoption by the end of it.
Really when it comes down to it.it comes down to workflow and workflow is broken down into 4 levels..... Organizational- information across the organization (eg patient enters ED, then goes to lab, then up to unit, then down to radiology and the system is capturing all that information) Departmental- Inforamtion across the department Role- Consulting amongst roles and different clinicians
lastly User-User based workflow, what do I do everyday....this is what most people think of when speaking of workflow, but this is the last level to address.
There are opensource offerings today that hospitals should really look into. The opensource offerings can save hospitals millions of dollars and have them up and running in a much shorter timeframe.
OpensourceRN wrote:Ricu
Great points......Problem with IT today is that the vendors wanted to take hospitals (even for the last 20 yrs) for all their money, with very limited scoped products that were not fully baked or some that were even over baked (so many bells and whistles when all you needed were the fundamental capabilities)and you only get 5% utilization of the product because it is not user friendly and very complicated. An integrated solution makes sense for the most part, but vendors do not do "everything" perfect. Best of Suite often is a great way to move with technology.
There are opensource solutions already on the market to help cut the costs significantly. The challenge is that with an opensource solution, you are not going to get the Prettiest application. So you need good leaders to understand what the needs are and guide your clinicians to a solution that works and is proven and doesn't take 10 yrs to install with no user adoption by the end of it.
Really when it comes down to it.it comes down to workflow and workflow is broken down into 4 levels..... Organizational- information across the organization (eg patient enters ED, then goes to lab, then up to unit, then down to radiology and the system is capturing all that information) Departmental- Inforamtion across the department Role- Consulting amongst roles and different clinicians
lastly User-User based workflow, what do I do everyday....this is what most people think of when speaking of workflow, but this is the last level to address.
There are opensource offerings today that hospitals should really look into. The opensource offerings can save hospitals millions of dollars and have them up and running in a much shorter timeframe.
Hi again Opensource,
Thanks for providing some good insight into what exactly these information systems are really supposed to do. Obviously this isn't always clear in application. You touched on another point that I'd like to address; overdeveloped systems. While technically possible to design, building many "enhancements" into systems that will never be used is wasteful. It's a little like buying a car or home entertainment system. Bells and whistles attract the attention of buyers who in this case, frequently have little real use exposure or none at all. The end-user would likely do without the "useful" options rather than invest the time into "personalizing" settings. I'll give the example of using a certain cardiac monitoring system. About the only specialized feature that I use with regularity is S-T monitoring. Setting it up is a pain in the "J point" and the EASI configuration of electrode placement is artifact prone. Tracking S-T is crucial for patients having an MI so I deal with it. Vendor reps like to say that the artifact problem is related to skin prep but in practice there's a lot more to it than that. I just can't wait for the latest version to come out. I bet it will have remote defibrillation or perhaps an ascultate lung sounds enhancement...
ok I just spent 20 minutes typing in reply to your question but it got lost in cyberspace, maybe there is a way to save my work halfway, any in a nutshell this is a tremendously complicated, multifactorial question. Just letting you know that I am continuing to seriously ponder it
