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14 Comments

  • kenju
    kenju

    November 28, 2005 at 4:36 am

    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.


  • angry doc
    angry doc

    November 28, 2005 at 6:15 am

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


  • Jenn
    Jenn

    November 28, 2005 at 7:37 am

    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.


  • Moof
    Moof

    November 28, 2005 at 8:08 am

    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


  • The Platypus
    The Platypus

    November 28, 2005 at 9:14 am

    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.


  • Kim
    Kim

    November 28, 2005 at 12:07 pm

    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.


  • DawnCNM
    DawnCNM

    November 28, 2005 at 12:12 pm

    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.


  • Kim
    Kim

    November 28, 2005 at 12:49 pm

    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!


  • angry doc
    angry doc

    November 28, 2005 at 4:48 pm

    *Ouch!*

    But it’s true! Especially just before the 2pm change of shift…


  • Third Degree Nurse
    Third Degree Nurse

    November 28, 2005 at 6:41 pm

    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.


  • Jodi
    Jodi

    November 29, 2005 at 5:52 pm

    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.


  • Unimum209
    Unimum209

    November 29, 2005 at 11:19 pm

    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.


  • Dave Harmon
    Dave Harmon

    November 30, 2005 at 8:55 am

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


  • missbhavens
    missbhavens

    November 30, 2005 at 2:54 pm

    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!


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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