What is a nurses priority in a hospital? Giving great patient care right? Wrong. To me, these days, it feels like documentation is the most important part of my job. The emphasis now in the hospital is have you filled in all the blanks on the computer that you need to in order to be compliant with JCAHO, Medicare, etc. Have you documented location, quality, aggravating factors, level of pain? After giving pain meds did you revital and redo level of pain 30 minutes after? Did you do discharged/admission vital signs? Did you reconcile all meds and record last time the med was taken? Did you fill in all of the many blanks around conscious sedation? Did you do the proper trauma charting so that statistics can be gathered? Screen for MRSA, VRE, TB. Did you screen the patient for potential abuse, suicidal thoughts? And these are just a few.
I spend the majority of my time doing documentation these days, crossing t's, dotting i's, filling in the myriad of blanks that need to be filled in. My documentation is tracked and if I don't do it right, I am given a note. A naughty nurse note. If it happens again I am placed in the staff time out chair in the middle of the ER. A third time? 20 lashes with a tourniquet.
o if you wonder why the nurse doesn't come in your room that often it is because she is out there documenting all the things that are required.
4 comments:
The first time I overhead the nurse asking the screening question "Have you been exsposed to anyone you know has tuberculosis?" I was like, "uh, he's here for an ankle sprain, I don't think TB has anything to do it". She was like "duh, it's just a dumbass question I have to ask everyone". I was like "That's hilarious. I am sure you pick one up all the time".
Amen, sister. Surgical services can be even worse. We have like 10 checklists, all redundant, asking the same things in different ways. We have to piss off the surgeons by making them sign 6 different forms, which seem to change every week or so on the joint commission's every little whim. Then we have to do all the screening as well for MRSA, TB, domestic violence, etc. It is priceless, though to see the expression on the 25 year old giormous 6'2" male when we ask him if he is being abused. He's like "what does that have to do with getting my knee scoped?"
I know what you mean, my challenge is we do not have electronic charting so I am have to do narrative charting which I have not done in years. Though I must admit it is much faster than electronic charting.
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