Documentation frequency

By Tamsyn Weaver posted 04-01-2018 05:29 PM

  
My unit is a 36 bed psychiatric unit taking ages ranging from 18 years and up with a variety of psychiatric disorders. Our patient's have a variety of co-morbidities but usually come to our unit "medically stable." Currently we are charting a head to toe physical assessment twice a day, a mental status nursing note twice a day, plus other charting like education, fall risk, IPOC, delirium assessment, pain assessment, braden, and on the early warning system (EWSS). All this charting takes nursing's time away from the bedside with patients. I am wanting to decrease the amount of charting nursing is required to do.

For those of you that work on units similar to mine, how often are you charting on the patients and what are you chartings? 
I appreciate any information you can provide!
Tamsyn
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01-22-2020 05:51 AM

I work in a similar environment.  By policy, our shift assessments include: pain, suicide, skin, fall, nutrition, education, care plan w/ note, and anything we have provider orders for (like CIWAs, etc.).  Our shift assessment flowsheets also include an extensive psych assessment (coping, behavioral, emotional, speech, etc).  To be honest, I stopped using the psych assessment flowsheets because 1) our providers never look at them; 2) they aren't required by policy; 3) the next shift doesn't really care what I clicked; and 4) they are a waste of time and contribute nothing to patient care.  Much of the flowsheet content is redundant busywork (we have five different places we can click "anxious").  I haven't used them in over half a year and haven't gotten any pushback about leaving them empty.  Clicking a box that says "agitated" isn't useful without a description; that's where notes come in.

Our hospital has a shared governance system.  Bedside nurses are encouraged to submit ideas for improvement that make their way through inpatient councils.  In your case, it sounds like a good opportunity to re-craft your charting to something more meaningful for your patient population.  It's worthwhile to pursue, but it will probably be a titanic project.  It will involve policy and software changes, which can snowball into huge undertakings.  I do, however, really encourage you to pursue it.  The electronic health record should enhance patient care, not become a barrier to it.

Good luck.

05-01-2018 08:26 AM

We are in the same boat unfortunately. Our unit is IP and we work 8 hour shifts. I come from a med-surg background and saw the benefit of a q12 head-to-toe assessment, for instance, but our unit is psych and as long as the patients are as medically stable as they are generally supposed to be, I think that a behavioral health assessment q shift (first and second shift) is all that should be required if a head to toe has been done once; considered that they are not on our unit for medical conditions. We also do care plans at least twice a day. Then of course we have physical charts and an official form for hand-off that is completed. Once again; unfortunately lots of charting. Some double-charting also.