October 3, 2007, 10:31 am

The Pursuit of Perfection


Does anybody rememer when an actual registered nurse ran the Central Supply department?

I don’t remember if I was assigned or if I requested it, but we had one whole day to shadow a nurse in a specialty, back in college.

What a cushy job! Put trays together, run the autoclave, make sure the floors had what they needed in terms of sterile equipment…no patient contact!

At least that is what I thought at the time.

I’m sure it had its pressures, but why on earth would you need an RN to run Central Supply?

I can’t imagine that is done anywhere anymore, but I’m interested to know if you know of any exceptions!



The saga of Blogger T. Squirrel continues.

His mom and sibling showed up this morning to partake of the Squirrel Chow, so I guess the whole family has adopted the back yard as their territory!

It will take more than seven cats and two dogs to scare this intrepid group of rowdy rodents!


I’m not perfect.

I’ll wait a moment for the shock of that statement to subside.

But, work wants perfection. No, Joint Commission wants perfection which means work wants perfection which means I am expected to be perfect.

You know what they say “runs downhill”.


There is one small problem.

I can’t be perfect.

I chart neatly enough to consider framing it. I was one of the first nurses to actually complete entire medication reconciliation reports even as I mentally screamed in frustration over more paperwork. The nurses on the floors know who I am by the quality of the written reports I fax upstairs. My patients are happy with their care and I work well with all the doctors.

I do the best I can every single shift; I try to meet every single requirement, dot every “i” and cross every “t” and document my ass off so that administration is happy. I run my ass off to make sure that my patients are well cared for so that they are happy (and safe!). I do everything for everybody and all I get in return is…

Notices of what I didn’t do.


Every registered nurse in the facility gets a letter from the hospital administrator delivered to their home decrying the state of compliance with the fifty million minute Joint Commission requirements for documentation. Guess that mock survey didn’t go so well when it came to the paper trail.

The one chart of mine that gets audited doesn’t have the medication reconciliation record signed, and so I am listed as “not meeting the standard.” I have no idea which chart. For all I know, it was a three page record and I forgot to sign page number three. But, I “don’t meet the standard”.

The hell I don’t!


It’s not just the patient documentation we get dinged on. It’s how we have to chart to get paid.

Here’s an example. I had a critical patient who was going to surgery any minute; the surgeon was at the bedside. I’m flying to finish the documentation and get him ready to go when a patient walks in who is having either an heart attack or a pulmonary embolism – who knows? He looks sick. The department is full, no one else is available to bring this patient to a room, so I stop the surgery paperwork and quickly get the new patient on a monitor, EKG’d and put in an IV.

I run back out just in time to finish putting the paperwork for the surgical patient together and off he goes! Back to the MI/PE patient I go to finish my assessment, when I realize I did not put the “stop time” of the surgical patients IV antibiotic on the chart – it had finished as he was being transported out the door.

We won’t get paid for that IV. Never mind I charted it under the “med” section. Never mind that I charted it under the IV section. Never mind that it is in the narrative, also. There is no “stop” time on the chart.

So we won’t get paid.

If we put in an IV, begin a saline bolus, push Zofran and Morphine for pain and then hang an antibiotic via IV piggy-back, we MUST chart the IV push meds as the initial charge. Not the bolus for hydration. That is secondary, as is the piggy back IV.

Or we don’t get reimbursed.

Yes, we have to remember inane details like that. What the hell has it got to do with nursing care?


I’m tired.

  • Tired of jumping through regulatory hoops.
  • Tired of being bombarded with minutiae.
  • Tired of working my butt off only to get “dinged” as “not meeting the standard” because of one signature.
  • Tired of charting for reimbursement instead of focusing on the patient.

But you see, no one cares.

Oh, they care about Joint Commission. They care about how you chart your IVs and the order in which you charge for them. They care that you put a number on the pain scale and repeat it after a medication is given. They care that you count the narcotics even though you have a computerized medication dispensing system that should do it for you. They care about anything and everything except the nurses actually doing the care.

They want us to be perfect and I am not perfect.

Guess that means that I “don’t meet the standard.”


  • Denise Hurst

    October 3, 2007 at 11:08 am

    Amen, sister!

  • Julie

    October 3, 2007 at 12:21 pm

    It ruffles my feathers, too. Patient care is only important after the Press-Ganey is returned with low scores.
    Missive from Management: Hey, while you’re hopping around backwards on one foot, please try to bend over and kiss this… and don’t forget to document your actions and my response. Thanks so much!

  • Onehealthpro

    October 3, 2007 at 3:37 pm

    Bless your heart. And where are those leaders while you’re experiencing the crisis? Are they on the unit seeing the chaos their inane decisions have created? Are they thanking you for giving your best? Have they even bothered to figure out that you are giving your best? On behalf of patients and the family and friends who love those patients, I would like to say thank you. And may you find encouragement to continue giving your best.

  • Beastarzmom

    October 3, 2007 at 4:00 pm

    Having switched over to the technology supporting all those patient care behaviors, but with wonderful memories of actual patient care, I can truly second that emotion!
    We now have to put in all kinds of “stops”, “hard stops”, “warnings”, etc. into every application used for patient care because some agency or regulatory body or insurance payor requires it. Then we have to listen to the pain all these things cause the caregivers.
    I know JCAHO and other accreditation groups have good intentions and I’m sure some good has come of the regulations, but holy smokes. I think it’s crossed over into the ridiculous now…

  • ERnursey

    October 3, 2007 at 6:03 pm

    I’ve said for years, administration doesn’t give two shits about the quality of patient care being delivered, as long as all the paperworks is done. And if a patient is unhappy, they generate another form.

  • medrecgal

    October 3, 2007 at 7:46 pm

    Guess this insanity is the downside to one of the mantras we always heard during my HIM courses: “Not documented, not done.” The degree to which this holds in your post here makes it border on ridiculous. But that’s JCAHO for ya! Unfortunately health care has become less about either of those concepts and more about arbitrary standards and quotas and making the numbers look right. Another symptom of the need for less bureaucracy and paper pushing. Guess all the documentation is the manifestation of a bad case of “CYA” and practicing defensive medicine. It’s sad, indeed.

  • Mother Jones RN

    October 3, 2007 at 10:06 pm

    And people wonder why nurses are bailing out of the profession. Oui!

  • Robert at Kintropy

    October 3, 2007 at 10:46 pm

    What an awful cycle. If it helps, I and my family understand as patients what you’re going through. We see it in home nursing: lots of charting, usually at the expense of at least time with the patient.

    It also leads to some false sense that all the bases are covered because it is in writing. During our daughter’s most recent hospitalization, her nurse (one we also knew well from home nursing) documented all her many allergies, etc. well pre-surgery. I reminded everyone verbally before surgery.

    You know the rest. The chart was not reviewed; one of the doctors used latex gloves and an iodine prep. Luckily, Hannah didn’t react much, but I’m sure insurance got paid, costs were recovered, etc.. Frustrating!

  • Eric

    October 4, 2007 at 12:05 pm

    Wacky idea as to why RNs ran central supply back then:

    Before women had equal educational and employment opportunity, their choices for a degreed gig with some respect pretty much ran:

    Teacher/School Administrator

    RNs at that time were essentially all women – if you wanted to hire a smart college-educated woman for a position, hiring a nurse was a good way to do so. Look at United Airlines and the first air hostesses – nurses.

    It’s a backdoor affirmative action program to give women an administrative/management gig without saying so.


  • Disappearingjohn

    October 4, 2007 at 3:13 pm

    We are actually a little luckier as we are not a JACHO hospital! Believe it or not, we “opted out” and are accredited by the state agency (they still follow JACHO standards, but they are a little less insane).

    We still achieved Magnet, still are a Level 1 trauma center, and now a stroke center, too…

    but no JACHO visits! (still have state ones, though!)

  • ellejai

    October 7, 2007 at 9:41 pm

    How about “Electronic Medical Records”,what they call paperless charting, trying to make seasoned nurses with otherwise excellent documentation skills do this in Resuscitation during a Megatrauma code? Some things need to stay on paper(what if I delay documentation looking for the “bleed-out” icon?)I’d prefer not to get diciplinary action for this….again.

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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