No doubt completing these charting requirements are simplified for today's nurses, but these nursing notes provide lines and lines of very little of substance for doctors to read, read exactly the same from patient to patient (and hence are ignored) and once something is found (like the social issues noted), no description of the issue is provided.Note #1
"Patient Acceptance Note
Patient Direct Admit from home. Awake, Alert and Oriented. Patient oriented to BR/ER light, bed controls, TV/radio, patient education channel, telephone, bathroom, visiting hours, overnight stay and call light. Vital signs taken and recorded. Pain status assessed. See flow sheet for vital sign assessment.
Documented by: Sally Smith, RN 4/13/2008 at 5:59 PM."Note #2
Problem: PAIN
Goal: PAIN CONTROLLED TO TOLERABLE LEVEL FOR PATIENT
NO C/O PAIN NOTED.
Problem: HIGH FALL RISK
Goal: FREE FROM ACCIDENTAL PHYSICAL INJURY RELATED TO FALL
BED LOCKED AND IN LOW POSITION. SIDE RAILS UP X 4, CALL LIGHT WITHIN REACH.
Problem: RESPIRATORY
Goal: RESPIRATORY FUNCTION AT PATIENT'S BASELINE
NO REESPIRATORY DISTRESS NOTED.
Problem: HEMODYNAMIC STABILITY
Goal: PATIENT WILL MAINTAIN ADEQUATE TISSUE PERFUSION/HEMODYNAMIC STABILITY
VITAL SIGNS STABLE, AFEBRILE.
Problem: DEHYDRATION (NAUSEA, VOMITING, AND/OR DIARRHEA)
Goal: RESTORE/MAINTAIN FLUID BALANCE
+BS; CARDIAC DIET. NO NAUSEA/VOMITING NOTED.
Problem: EMOTIONAL STRESS
Goal: PATIENT WILL VERBALIZE LESS ANXIETY
PT HAS SOME FINANCIAL AND "HOME" AND FAMILY CONCERNS THAT SHE WOULD LIKE TO DISCUSS WITH SOCIAL WORK.
SOCIAL WORK CONSULTED."
Aspects of the new electronic medical record was not made for doctors or our patients, but clearly for quality assurance administrators.
Thanks, folks.
-Wes
8 comments:
I always get a kick out of arcane "nursing diagnosis" that are only used for purposes of passing nursing school and charting something that no one will ever read.
So the point is to get the patient to "verbalize" less anxiety, not actually experience less anxiety?
You are totally right, Wes... but it extends beyond nursing notes. We have electronic doctor notes that function the same way. A fellow or resident reads from a template, filling in the blanks. When I go to sign it, standard language appears. All of this verbiage is designed for one purpose only: to satisfy compliance officers/quality assurance administrators/billing auditors.
Oh, for the days of a handwritten SOAP note.
I can just picture the memo posted on the staff bathroom wall:
"If we don't achieve 95% compliance with the 'BED LOCKED AND IN LOW POSITION. SIDE RAILS UP X 4, CALL LIGHT WITHIN REACH' charting initiative, then we won't get our gold star certification of nursing quality."
Along with a bar graph showing the week by week compliance for each nursing unit.
"The unit with the highest compliance gets one free parking pass each!"
Computerized charting for nurses is not helping us do our jobs better. Some systems for charting are better than others perhaps, but I have not seen or heard of a system that saves time or improves efficiency or do much of anything except create problems for the people who lay their hands on the patients.
And I have seen employees get disciplined and fired for being "negative" about the new systems. Honesty isn't getting some nurses very far.
Tell me the computerized charting helps a data collector or quality control person and I will say 'fine'. Tell me it helps nurses give better care and I will laugh in your face.
I am from the software industry and I am reading more of these types of comments/complaints. We love to hear them but how about some solutions??? What are the expectations of EMR and how would you like to see EMR utilized? The days of trying to read illegible (and inefficient) handwriting are almost out door for many reasons. I was a clinic manager in my past life and we spent/wasted more time going to the back to the physician to figure out what he/she wrote!
Where is your solution?? Didn't see one here at all??
Great post. As a new nurse I find a majority of the "required notes" completely useless from a patient care stand point. Charting is more like checking boxes for CEOs and protecting my rn license ILO painting a picture of whats going on with the patient.
Solution: not sure because the legal and social demands place restrictions and only allow for a cookie cutter approach to healthcare instead of best individual care.
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