October 8, 2006, 10:46 pm

When Will It STOP?

sign

Neat sign!

Of course, I’m 51% Nurse,

20% Simple Human,

And 29% Rock Goddess.

Not too many people realize that.

What?

Why are you laughing?

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Living as I do in the San Francisco Bay Area, one would think that I would see the occasional sports figure or rock singer, either on the street or in an ER.

Nope.

I can honestly say I have never taken care of anyone famous.

Ever.

Not even someone famous’s sister’s friend’s cousin once removed.

Oh, I’ve missed ’em by half-an-hour.

I think they’re avoiding me.

So, I make this public plea: if you are a famous rock star and you EVER need an ER, email me so that I can arrange to be your nurse.

I promise I won’t blog about it.

Trust me.

Really.

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I try really hard to keep a good attitude at work.

I try to see the benefits of new policies, work with changes and hold opinions until I actually see how things pan out.

(Any co-workers reading this will choke at that last sentence. Let’s just say I’m not shy about verbalizing….anything.)

But sometimes you just feel like enough is enough, that you are already working at the maximum level of efficiency you can muster.

Then you get hit with something new.

Again.

And you know a line has been crossed.

*****

So what is so awful it has me wondering how I’ll be able to function?

A new piece of paper.

No, let’s be honest; it’s a different piece of paper.

*****

We all know about the medication reconcilliation forms. First, we had to do it on admitted patients.

We did.

Then they expanded it to every patient who arrives in the ER.

We did.

Then they told us that we had to fill in every single piece of information including dose, schedule and last dose taken.

We have.

*****

At the same time, we were told that verbal reporting to the medical/surgical units would be replaced by a written, faxed report.

A report that would not be part of the chart. Just a way of giving the admitting nurse a time-saving way to take report and have a written note of the patient’s history in front of her.

I did not object to this. If I was the admitting nurse on the floor, I would love a faxed report, as I would not have to break away from patient care to take a verbal report.

It was/is extra work in the ER, especially if you are writing a thorough report; essentially it is double-charting as we have to put down the most recent set of vitals, the medical history, medications given and lab results pertinent to patient care. But, as it is a rather open-ended document, it gives you a lot of lee-way on how you choose to write the report.

But we did it.

Then they said we had to send written reports to Intensive Care and the Mental Health Unit, two units where verbal communication is preferrable. Critical patient status changes quickly and it is easier to describe patient affect and behaviour verbally for the psych nurses.

But we did it.

*****

Now it has been decided that we must have a “house-wide” written report.

The report proposed is so detailed it looks like a flow-sheet of an entire shift. It is truly a case of double charting, as after the “trial” period, the plan is to make it part of the permanent chart, signed by both the sending and receiving nurse.

When will it stop?

*****

I’ve had it.

The emergency department already carries an inordinate amount of responsibility when it comes to initiating required paperwork.

Let me be more specific. ER NURSES carry an inordinate amount of responsibility for required paperwork.

  • We are already doing what should be the responsibility of the admitting physician, and that is filling out the medication reconcilliation form.
  • We are already filling out a paper report in addition to the medication form and the “regular” nurses notes.
    • Those “regular” nurses notes are the legal record and had better be court-ready.
    • I can’t tell you how often I’ve heard stories of how a set of nursing notes has stopped a lawsuit.
    • The hospital administration should be bending over backwards to allow us the staffing and the ability to chart appropriately, not adding so much paperwork that that the patients begin to suffer. It would behoove the physicians to back that up; when our charting is concise, they benefit in the long run.
    • The written report does everything for the receiving nurse and puts the entire onus for re-charting on the sending (ER) nurse.

Every additional piece of paper they add to the already voluminous amount we are required to fill out in detail:

  • Takes a nurse away from the bedside
  • Makes it harder to provide accurate, complete nursing care
  • Makes it harder to do the actual legal charting we are required to do.
  • Increases the wait time for patient admissions, as the patient can’t go up until the report is faxed and the medication form is complete.
    • Add another 2-3 patients to the ER assignment, and it isn’t easy to get to that paperwork. The patients wait.
    • ER nurses have no control over their assignment. They can receive a critical patient or have a patient go bad at any time. The paperwork must be done. The patient waits.

And guess what happens when a patient has to wait? For anything?

PATIENT SATISFACTION SCORES DROP.

Some units live and die by those scores.

*****

I love paperwork. I really do! I love charting; it’s an art form.

I’ve never been militant in my life. I’ve never refused to do anything when it came to paperwork.

But I have reached my maximum ability to provide the care and attention my patients deserve and do all the increasing amounts paperwork required by my hospital.

And they require the nurses to do it.

*****

Despite what you have read above, I work in a wonderful ER.

No patients in the hallway ever. Experienced nurses. Fantastic doctors. The expectation is that we will give excellent care and we are proud of it.

Patients ask for my facility by name. Some drive hours to get home when sick so they can come to my hospital.

I really do enjoy patients, whether they be homeless, drug seekers, having chest pain, dealing with a migraine, status post emesis x1 or rushed in by parents with a fever x 30 minutes.

They’re my patients.

I love my job.

It’s getting harder to do that job to the best of my ability because the amount of paperwork is on the verge of oppressive.

What the hell am I supposed to do?

7 Comments

  • Julie
    Julie

    October 9, 2006 at 3:51 am

    Oh sheesh. What will they think of next? Reducing paperwork, to make this an electronic submission you can just instant message to the unit? I don’t know who approves these ideas, but one has to wonder if they’ve ever set foot in a nurses’ station.
    Rock on, Kim. Rock on.


  • Rita Schwab
    Rita Schwab

    October 9, 2006 at 3:57 am

    Serious issue – really. Paperwork should add to patient saftey, satisfaction, etc. Sometimes we end up with paperwork that just adds to the demise of trees.

    How many of these requirements actually come from Joint Commission, and how many have been added by your own administration? The local add-ons may be easier to change.

    Send the essence of this post (rock-goddess part optional) to the people who need to see it.

    They can’t know how you and your patients are personally affected unless you enlighten them. Don’t be shy (ha!) Speak up!

    Joint Commission:
    http://www.jointcommission.org/AboutUs/ContactUs/

    Should I end up in your ED, I would want my nurse to actually see/touch/talk to me once in a while – not spend all of her time with her nose in a chart.

    Besides, I’d want time to make an impression on you so I could get written up in your blog. THEN I’d be famous!


  • DisappearingJohn
    DisappearingJohn

    October 9, 2006 at 8:28 am

    I agree with you completely on the written report thing. That sounds ridiculous. As an ED Nurse who started as a floor nurse, I wouldn’t want a written report. I want the ability to ask questions, get responses, and have a more patient specific report, not a one-size-fits all report…

    We actually just rolled out the med reconciliation for all patients a month ago. Its okay for the patients that are triaged in, as we have a form that they fill out (to get their mind off the wait) taht makes it a lot easier. Its all the ambo’s and prioity ones that it is a hassle on. If the patient’s tubed, we have to call everyone and their aunt to find the patient’s meds… we are even supposed to call their pharmacy, if we can find out which one it is, to verify dosages…

    Hopefully someone out there is listening to you, Kim!

    (btw… Journey is probably my second favortie band from my teen years..STYX beats them out by a hair)

    I may not be a rock god, but I can air guitar with anyone!

    John


  • Melissa
    Melissa

    October 9, 2006 at 10:57 pm

    I know what you mean. I blame it on middle management nurses who have way too much time on their hands. They need to impress their bosses and the only way they know to do that is to come up with new forms and policies. They need to work a few shifts a month to see how their new ideas work.


  • Annemiek
    Annemiek

    October 10, 2006 at 5:22 am

    Find out who who comes up with the ideas for all the forms, and get on that committee to have a say in it. Yeah right, in your spare time.
    I think the med reconciliation has gotten out of hand. I see the benefit for an admitted patient, but not for someone that comes in for an outpatient test and then goes home.
    In our hospital they started the written report from the ER, but we have not really been using it. The verbal report has the preferance, that way you can ask questions.


  • Grand Rounds 3.3 at Unbounded Medicine
    Grand Rounds 3.3 at Unbounded Medicine

    October 10, 2006 at 9:00 am

    […] Kim -the 51% nurse and multiple host of blog carnivals- blog about the evolution of how making nurse reports has changed to mean significantly and this supposes an additional work. […]


  • Sue
    Sue

    January 14, 2007 at 7:22 am

    I take offense to the middle mgt. comment above. It has nothing to do w/ middle mgt. It is a JCAHO pt. safety initiative. Use your time and energy to write to the JCAHO address above. It is very dif. to pass new standards to staff nurses and a good middle mgt. nurse would never initiate something that they haven’t done themselves. The concern w/ everyone doing documentation and no one at the bedside is a fight that middle mgt. fights everyday!!!


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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