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.
