I have no idea what the purpose of the RN "plan of care" notes are in Epic. Never seems to affect anything. I'm sure they hate having to spend time entering them.
They’re embarrassing. We can’t write them really - we just click stupid boxes and it autogenerates like we don’t actually have anything useful to say and it reinforces how useless and pathetic our “notes” are to the real professionals. No one reads them because they’re useless but subconsciously it reinforces everyday when you skip over it that nursing’s intellectual contribution is useless.
I really wish they didn't even show up in the progress note tab, exile them to flowsheets or something. Because they're not progress notes.
I wish nurses had the time and bandwidth to put in a real, brief shift summary progress note but there's so much other clinical and admin BS they dump on y'all.
This. My time is too valuable for double charting. My note 95% of the time is just a mention that I discussed xyz abnormal findings/condition changes with the doc to cover my butt.
My last facility used to get on my case because I never wrote any nurse's notes unless something exceptional occurred. Everything else was charted in the flowsheets. I'm not wasting my time to say the same thing twice. Fuck off, admin.
I also report by exception where I work, I couldn’t imagine doing it any other way. Why would anyone expect a progress note from my pt if all they did was sleep for 8 hours? I’ll document that in the flow sheet but I’m not about to write a paragraph about it.
Everywhere I’ve ever worked nurses chart the real info in flow sheets with little comments added to the spreadsheet. It has the perk of being just about impossible for patients to access via MyChart.
I agree a 3 sentence narrative note of each shift would be helpful but I wouldn’t want to clog up the notes section with it.
Worth putting IMO, especially if something actually happened, but TBH even a "BM x 1 o/n" would be helpful since flowsheets suck to get to and read from our side in our build of epic.
The issue is it’s difficult for you all to see the flow sheets, not that we aren’t also writing notes. Like wtf is the point of us even documenting our assessments if nobody else can even see them?
Well and that flowsheets are not exactly human-friendly for anything but data. Text assessments, if you can even *find* them are much more annoying to use in flowsheets IME
Yes, I remember the good old days, not so long ago, when the overnight RN note was ridiculously useful. As a resident, pre rounding, I could always fine a line or two in the binder like "patient a little nauseated after dinner, slept well, woke up at 3am to void, fell back asleep easily." Like, that's exactly what I needed to know about the night.
You’ve articulated my feelings perfectly - I *hate* reading other nurses’ documentation, and this is why. It’s cringe-inducing to go from the concise, medically-relevant physician notes to, “call light within reach, patient denies needs, will continue to monitor”-type bullshit. I chart the bare minimum and only include notes when I have something relevant to add, chart auditors be damned (kind of).
Nursing contribution is not at all useless!! I absolutely need to know what nurses are thinking and value your opinion. Skipping over the “care plan” fluff note doesn’t make me think nurses are dumb … but I do think the person that decided that nurses need to write that note is dumb.
Everyone knows they’re useless. So they just make them as quick to mindlessly check through as possible. But it makes the ivory tower academics feel like all their hard work “elevating the profession” with nursing diagnoses and shit has a point.
I'm in quality and work closely with risk. We do read them if and when we have a case that needs review or when DOH or TJC show up and ask to pull random charts. I specialize in Behavioral health at my facility. The amount of BS I see in charts is terrible. They claim the patient is clear and then I see the patient back within 72 hours. Our readmission rate is good awful, but I'm told HBIPS is more important. Seriously.
Patient meeting mobility goals
Patient fall risk precautions discussed
Maury on in patient room
--
Like, what the fuck are we doing. This just isn't useful documentation. If documentation isn't useful, then it needs to go. Enough is enough, for fuck's sake.
THANK YOU. And progressing? I was called into an office for putting in my care plan that we weren’t meeting the goal of the patient remaining free from infection because they got VAP. I was told I could only write progressing because things are either progressing forwards or progressing backwards and we don’t need to specify which… what is the point?
It's useful if they had a fall because then we can claim they were discussed with the patient and you likey have a fall risk established. As for for the TV that's obsessive, but it does establish the time you made a round.
That's exactly how risk and quality see that information.
But here's a question: if the "Plan of Cares" are robotic, non-specific, and ludicrously inappropriate to the situation, how does that acquit the institution from a risk management standpoint? For example, if a nurse documents in the Plan of Care that their GCS 3 comatose patient received education about the use of the call light because they've been directed to do so for every patient at the risk of being penalized in some way, how does that add anything of value? I would argue that bad documentation is more of a liability in some cases than no documentation.
I mean if they actually documented that they did that with a comatose patient then technically they documented incorrectly. A proper EMR would allow the staff member to document the patient is unable to take directions.
I couldn't agree more. Other HCPs could actually get useful info from our notes if they didn't automatically ignore them by rote due to the nonsense care plan notes.
Yes the auto-generated stuff is useless, but the stuff nurses manually put in that have actual information about the patient is extremely useful most of the time. I'm always grateful when the RN puts more into the note than the auto-generated stuff.
"Goals today: get better, but stated in a paragraph of blown in text"
I don't blame the RN for these, but as a resident I would click on them always hoping for relevant info. But finding... nothing.
Great. What do they do with them? Are they useful in some way? I'm not trying to be snarky. Really, if they have a helpful purpose, I genuinely want to know.
As far as I know at my hospital, they just look to see it was completed each shift. Everyone knows they’re just for compliance at our hospital. Nobody really cares how they’re filled out, just that they’re done to a certain minimum standard.
Honestly, we RNs don't know what they're for either. We just know that we are required to do them. I literally throw it in at the end of my shift just to have it done. It does nothing but take time from me.
Do y'all have the nursing notes that just say "Wiped down all high-touch surfaces including IV pole, computer keyboard..."? Who decided that basic housekeeping needs to be part of the medical record?
We don’t do that, but we do have to chart in the flow sheet that we gave report to the next shift, which is pretty ridiculous as we always give report to the next shift. We also get audited and talked to if we don’t hit the “disinfected meter” comment every time we take a blood sugar. So it’s not a huge leap to see some admin encouraging this with some big “if it wasn’t documented it wasn’t done energy.” (Ofc, when there’s no housekeeping staff to do regular room cleanings…that of course is not documented anywhere).
You can make a filter that only shows you notes written by an attending physician/resident/NP/PA/student/pharmacist or such. I have one set up in every iteration of epic I’ve used.
That said, it does also filter out things like telephone notes from the MA and whatnot, so I don’t leave it on all the time. Just assists with chart review.
I wanted to do that, but some RN notes are important. RNs are can be the first Epic documentation that someone is decompensating. Or when something actually occurs overnight that needs documentation. I want to see that stuff. Not the stupid fucking care plan.
What's even more embarrassing is the existence of the [NANDA Nursing Diagnoses](https://www.ncbi.nlm.nih.gov/books/NBK591814/). Yes, we have been formally empowered to "diagnose" conditions...spoiler alert, they're mostly vague "at risk for" bullshit.
I've been critical of this since nursing school. Some nurses take offense, but they're pointless to me. And also embarrassing. All the time we spent in nursing school regurgitating that crap could have been spent on learning more about disease processes, procedures, medications, and hands-on skills.
My all-time favorite NANDA diagnosis is "disturbed energy field".
DISTURBED ENERGY FIELD.
and the interventions for it are laying on of hands or whatever by a nurse with appropriate energy field training. Like, reiki or what have you.
...NANDA diagnoses are fucking hilarious.
I graduated in 1995, so things were a little different then, but not hugely. One of our last classes was a critical care class, focused on learning higher-level disease processes and nursing care. Overall good class.
We each had to do a presentation on something for class. For example, one student talked about low molecular weight heparin, which was relatively new at the time. But we had one student...best way to describe her is that if she'd been alive in the 1700s, they'd have burned her as a witch. Her presentation was on "therapeutic touch". I'm thinking ok, massage therapy - not really critical care, but ok. The teacher volunteers to be her subject. I shit you not, student/witch proceeds to shake off her hands to "dispel any negative energies"; she then runs her hands over the instructor. about 2-3 inches over her skin. So nope, not massage, just Reiki bullshit. Worst part was, the instructor went along with it.
I lost a lot of faith in my profession that day.
So you can fire the nurse if they don’t do them.
Nurse charting is all about creating unsustainable awork loads, so when an eventual error occurs, admin can scrutinize the charting, find one slip up, and blame the nurse for the error. Ignoring the systems issues
"oh, see. i looked over your charting and even though you spent 6 hours keeping confused grandpa's face from meeting the floor, you charted mobility as a 2 at the start of the shift, but do you think it could be a 1 instead? Also, I don't see any turns documented"
I don’t do them. Am I supposed to? Yes. Has my manager ever mentioned the fact that I don’t in my quarterly chart audit? No. They clutter the notes section, which is generally the only useful section in the whole chart and imo make us look infantile. I refuse
I do them but I don’t make them a note. In epic if you just hit close it will chart them as done. No note needed. I’m only making notes on events or things I want the doc to see that I don’t want to call them about in the middle of the night.
Great tip. I still probably won’t do them unless my boss makes me but I sure as shit won’t autogenerate a note after when I do eventually get called out on it hahaha
Right, we have “documentation reminders” and in order to get them to go away that’s one of the things that needs charted on Q12. I only do it to get rid of the reminder. Half of the care plans aren’t even relevant.
RN plan of care notes are very helpful: if chart review reveals that the nurse is live-blogging about the patient’s non-slip socks, I can tell the patient is stable.
It’s stupid. All a “care plan” is, is a statement identifying a problem or challenge the patient is facing, and the steps we are taking to mitigate that with them. Then we just click to say whether the task/measure accomplished whatever goal we were trying to get to with that measure. It’s just a long way to say “this is a problem. We are trying A, B, and C. The problem is now solved/the problem isn’t solved yet.” Repeat. Just “problem solving.” lol that’s it.
They are worthless but it only takes about 10 seconds to click the same shit every single day and post it in epic.
No one spends any significant amount of time charting those.
Why do nurses have to complete a Falls risk assessment in the NICU? They are babies. They are all Falls risks. And I know this because they all have little "Falls risk" stickers above their incubators so I am not tempted to take them for walks.
Surely some family out there in the ether must have sued a hospital because their 2-day old premie escaped their bed and strolled down to the coffee shop.
Edit: On that note, it is truly staggering how strange anecdotal incidents influence hospital policy.
Why do ED nurses have to do a swallow screen on every patient who gets a head CT? Stroke or r/o stroke, of course! Headache, MVA, and the litany of other reasons people get a head CT, WHY??????
Why do we have to do them on people who are already on thickened liquids at home at baseline. Like hold on just choke on this 4oz bottle of water real quick and then I’ll get you your simply thick nectar packet and you can keep doing what you’ve been doing for the past 5 years
I was once told by a peds nurse that they have to do a whole fall incident report every time a kid falls even if they’re toddlers and fall literally every ten feet
I didn’t think the information gets reviewed routinely until one day I got a random email from someone in Infection Control that wanted me to look into a particular scope that’s been documented in several patient’s charts and they all got this rare bug (can’t remember the details, it was years ago).
Or to track issues with equipment, manage manufacturer recalls, look for trends with all sorts of shit. I just moved into Risk Management and the depth of the information is overwhelming, but I’ve already seen how it comes in handy A LOT for improving processes and catching potential patient harm. It’s wild.
I could potentially see that with an anesthesia machine vent or a probe, since those have direct contact with the patient, but stuff like the computer and echo machine don't make a lot of sense.
We traced a Stenotrophomonas outbreak to a portable ultrasound machine using serial numbers from charts. We backtracked to see if our infected patients had the same procedure done and if they had a unit in common. Sure enough, they did. We cultured it and found the bug on the tray where people leave their pens. It sequenced out as the same as our outbreak strain. We took the unit out of service, cleaned the hell out of it, and haven't seen an unusual number of that organism since. It still pops up from time to time, but it does show up randomly.
They all move around the hospital from patient to patient and are a potential reservoir for MDR organisms. They may not make direct contact with a patient, but the doctors, nurses, and techs to touch them do. And, such equipment is often difficult, if not impossible, to sterilize. Can't throw your echo machine into the autoclave (more than once)
>but stuff like the computer and echo machine don't make a lot of sense.
Unless you want to track potential software/hardware glitches. Any computer can fail or give a bad reading.
Surgical services can track outbreak pertaining to a specific scope like this. Happened in a local endo department and we heard all about it at our staff meeting, then had to double down on scope washing practice.
Usually? Nobody. When something goes sideways and the patient tries to sue the hospital? Then the lawyers will read them.
In terms of actual patient care decisions, they're almost never useful. Which is sad, because nurses know a LOT about what's going on with the patients each day and we've buried their useful input in a mile high pile of garbage.
A family member of a Hospice pt. sued a hospital I worked at, alleging that the patient's PCA pump malfunctioned and bolused her, causing her death.
Obviously, this was not the case, and it was 100% the cancer that killed her. BUT, this lawsuit was the reason our unit had to write down the serial number of every pump a patient utilized.
That really sucks. The worst part is the plaintiff could claim any individual part was responsible and make it even more difficult to disprove--for example, they could claim it was a bad channel on an Alaris pump that kept alarming, but how could you possibly track that down to prove/disprove? AFAIK the channels don't have individual serial numbers, and the channels float around them entire hospital.
Oh. But just this past year our hospital tweaked the workflow so that nurses do in fact have to scan the med, the patient AND now the channel (that has a serial number and corresponding QR code sticker on its face), all with hard stops in between to click something/confirm something, so you go back and forth between the computer and the patient bedside 3 times before it’s “charted”. Efficiency!
As a OR RN my dream is to reduce the time charting those damn serial numbers on every piece of equipment. Every new device seems to automatically get added to the list of things we chart, senseless. At least we should be able to scan the serial number barcode stickers and have it auto populate the chart.
This. I was a paralegal before I became a nurse. It's to defend us all from the occasional lawsuits. There is like one huge multimillion dollar settlement behind each piece of ridiculous minutia.
Im taking over as ICU director soon, and step one is going to be an audit of nursing documentation requirements. Even before doing it, I know of multiple redudancies/overlapping documentation requirements. Every initiative within the hospital seems to have "oh the nurses can do that!" as a solution and its burning everyone out. I cant get over admin scratching their heads over why over 50% of our ICU nurses have <2 years experience...
So the short answer is...almost noone reviews it. If they do, its almost never reviewed for anything clinically relevant
Good luck. I feel like there are a lot of clipboard RNs who justify their whole jobs by creating more and more useless audits for us to document. And someone is monitoring some of them (though it seems to rotate which ones they’re looking at), as we get nastygrams on occasion if we forget to check 1/10,000 boxes we have to check every shift.
Oh I know it'll be a fight. I've brought it up before and the answer I got was "yes we do keep track of everything they have to do." No one could provide me with that document so far. I suppose we will see🤷♂️
I gotta try and do something, I'm sick of losing all my badass nurses
Good luck, 90% of the charting we do is to fulfill JHCAO requirements and would probably be pretty hard to get rid of. During Covid they temporarily got rid of the extra charting at my hospital and it was so nice not having an a hours worth of straight charting to do in the beginning of each shift.
Fighting the good fight. Please keep us updated how it goes. I feel bad for our nurses that have to do all this charting and would love to see how someone else addresses this.
Imagine what could happen if we could actually focus our time and effort on taking care of patients!
-RN who was told during orientation that I spent too much time with my patients and needed to prioritize charting.
I'm so glad my preceptor was the exact opposite of that. But it might have been bad that we both felt the same way and I never developed the care for charting past the bare minimum.
> Every initiative within the hospital seems to have "oh the nurses can do that!"
I have to laugh at SCCM for that. SCCM has a huge ICU liberation protocol that has some good evidence for it, even if the actual recommendations are rather underwhelming. They've also promoted integration with Epic for documenting the A-F bundle.
I don't care whether a nurse documents, I care that they do it. It's too simple to just pencil whip the assessments (who actually does a proper CAM assessment after all). So why would I make them devote more time to the computer?
"If you didn't chart it, it didn't happen" is the annoying mantra of nursing admin. Meanwhile a good half of things charted by my peers definitely didn't happen.
I'm looking at you, coworker who charted that they gave their patient a bath an hour into the shift. Or charted an auscultation assessment for every single lung field on an ECMO patient that they only reposition for the most dire bed-soiling circumstances.
I love you.
It feels like the hospital falls all over themselves to satisfy regulatory requirements but never thinks about how to do it in the most efficient/least annoying way….and certainly never goes back to eliminate things that are no longer necessary.
In terms of anal, law firms have used e-discovery methods for years, and of course they are going to be using AI tools as well (with, presumably, human checks after a few scandalous AI flops in front of judges). One day someone is going to sue someone, maybe over the reliability of the device, maybe in patent litigation, somewhere.
At times I have been bemused by all the numbers we use, though, and although I know the mathematical universe is absolutely infinite part of me wants to think it will all get filled up and explode. EMR ID numbers, serial numbers, case numbers, all the gibberish that is on those labels on electronic devices of any kind, MAC addresses, IP addresses.
It is, of course, being stored somewhere, and more data one way or another to try to protect that data (which is bound to decay over time), and all of it is in server farms, preferably area where land is cheap but there's plenty of access to the electrical grid, and all of it making the planet hotter and hotter and hotter.
When we had paper charts back in the ice ages I used to review nursing notes. They would write relevant info and the notes would give a picture of what happened with patient overnight. Now with EMR I don’t even know where all their documentation goes. I don’t think they write notes as much anymore bc they’ve got to click so many buttons, who’s got the time?
The flow sheets make life so hard. I don’t even know what providers can see of the documentation I record. All of my head to toe assessments are in flow sheets, and I’m pretty sure providers can’t or don’t know how to access them. I also work in surgical stepdown & we follow ERAS pathway recoveries and providers can’t see all of my painstaking mobility charting, which I know because their notes always say “patient has not ambulated” when I forced them up out of bed to walk at 0300, & for some reason the patients always say they haven’t gotten up.
In theory flowsheet documentation for nursing assessments should give you the ability to trend data over time, such as orientation or neurovascular checks, but as far as I know the Epic flavor we use doesn’t have any data visualization tools like that.
Flowsheets are one of those things that you won't find unless you know where to look and you know what you're looking for. For example, let's say I'm preparing for a case in the OR for an inpatient and I want to know what IV lines the patients has. Some implementations of Cerner and EPIC will specifically import that information into my workflow, but for others I have to find a way into the Flowsheet and look at the dressing assessments to see "Oh, this guy has a central line." Finding that section of the Flowsheet takes a spectacular deep dive as there may be other sections labeled for IVs that have no information in them. Sometimes the category in the Flowsheet is not what it claims to be.
I use the flow sheets pretty regularly but it’s like you said - very poorly formatted and also 5 clicks deep in a submenu. I’ll use it if I’m looking for a specific piece of information like nursing neuro exam or CRRT start and stop times. But unless you knew exactly where to look and what the flow sheet was called, you would not be able to find any of that info.
That’s so asinine. What’s the point if not to record data for the providers?? That just means I have to double chart anything important- once in my flowsheets for my required BS and then also write a narrative note for you guys. I can’t even trend a specific item in the flowsheet to see values past the previous 24 hours. Clunky and useless.
And I was specifically told before a JCAHO audit not to put anything in a nursing note that was in flowsheets because it’s double-charting. But I also quickly learned that providers didn’t know how/didn’t have time to look at what I charted in flowsheets, so how else are they going to see a quick summary of relevant things that happened during my shift?
It's a lot more useful than you'd think. Most good systems let you just scan a barcode on each device, and it actually saves a ton of time in the long run by ensuring all the medical things are serviced at the right time, what supplies are consistently fully utilized to buy additional equipment, occasionally infection prevention if an infection can be tied to a particular piece of equipment, auditing each procedure always has all the correct things available etc etc. This kind of documentation is one of the most effective QC systems we have and it tends to be totally transparent to providers.
There are many many many dumb things we do for no reason, documenting what specific equipment is where is not one of them.
> This kind of documentation is one of the most effective QC systems we have and it tends to be totally transparent to providers.
I'll remember that the next time the thing I've reported broken for a year gets fixed lol
There's a whole thing called QA nursing. The job of these quality assurance nurses is to go thru our charting and bitch at us when we "aren't titrating every 5 minutes" or "why did you forget to chart your Q2 turns". Honestly if there's any part of nursing that's gonna be replaced by AI it's this.
I’m a QA nurse now, after 24 years of bedside. My messages are more like “Hey hate to bother you but you didn’t document the—fill in the blank with whatever joint commission likes to scrutinize—so could you please get it fixed?” I like to think if I can swoop in and get it corrected before the clinical director blows it out of proportion then life goes easier for everyone. I know I’m a pain the ass, but most of the stuff I review I do so because it’s come up in a survey.
I found out some hospital billing is based on reviews of Dr's. Orders, therapists progress notes, from the chart. Wife was in house for 3 nights with anemia. I got itemized bill and she was charged for i.c.u. care. She was never in i.c.u. Also charged for p/t, o/t based on progress notes. No p/t or o.t done. They got pissed when I mentioned Medicare fraud.
Just saw that personally. A patient of mine brought in some of their bills, and it turns out some PT facility they went to twice has been billing them as being seen three times a week for the last six months.
They had an order in January for 3x/wk for a month after surgery, but no secondary order as ortho said it was not needed. So now the patient's insurance is suing the PT, using my records and ortho's to document that she was never referred there after January.
That's insane. Considering the amount of garbage copy-pasted macro'd stuff people put in their progress notes, extrapolating billing from that is robbery.
Fraud is a great word to drop if you want billing departments to take you seriously. I had a surgery that I was ultimately billed zero dollars on bc I caught them upcoding and double billing.
Billing lady told me if you have charges for icu care, all other charges you may have, labs or xray say, those charges are increased just because it's an icu pt.
That actually makes some sense, especially for imaging. It’s a lot more work to move an icu patient somewhere, or you have to bring up the portable. A lot of med surg patents you can throw in a wheelchair or they’re coming down in just the bed with maybe one iv and an oxygen tank.
The serial numbers are needed in case some funky shit happens and they want to come back and say: oh that’s where the xyz came from! That’s what caused the patient harm. Not the hospital and its practices. It was the machine gone rogue.
On a personal note, I wasn't able to know what happened when my dad died and family is less than helpful, so being able to review the chart, literally hour by hour, has been helpful in giving me understanding and closure. Granted I know how to read a chart.
Edit: the records were ordered through proper ROI channels.
Serial numbers are critical for infection prevention investigations, especially contact tracing. Look up the [Olympus endoscope outbreaks from 2014](https://www.latimes.com/business/la-fi-olympus-outbreak-20150302-story.html). That's how the outbreak was traced back to the scopes.
We've done several outbreak investigations related to other portable, shared equipment where tracking who it's been used on has been pivotal. Any time we get more than 3 inpatients with an unusual bug, especially if it has the same sensitivity pattern, IP starts scouring charts for commonalities - floors, procedures, staff, equipment.
Because if something bad does happen, a sentinel event, they want to be able to look at any and all variables that may have been involved so they can ensure harm to patients or workers can be prevented.
Some info, it's redundant for sure, but some is useful for others who track things like that.
It is valuable info for infection control contract tracing. I can remember a hospital I work at having to contact several neurosurgical patients and let them know they may have been exposed to CJD that was tied back to a particular piece of OR equipment
Pretty much like any charting a doctor does only a few people will ever read it.
Billing and Lawyers.
And when you definitely know CQI is going to be reading the chart you'll be a bit more thorough.
I would think its probably in case of a lawsuit or equipment failure or blaming equipment failure theres the serial number of the machine. Everyone wants to sue these days.
I’ve noticed so much of this performative bullshit at my hospital. Everyone on the clinical side is tired of it but the MBAs in charge have mandated it so we do it. I highly doubt this stuff is useful in lawsuits anyway and if it is, it shouldn’t make everything more tedious and expensive just to be a solution when the extremely rare lawsuit regarding medical devices comes up.
dude the only time that shit will be reviewed is when the lawyers get involved. so that they can say dr so and so how come you didnt respond when nurse so and so said pt was nonresponsive.
Insurance auditors. We'll request years of medical records at a time, and if your documentation doesn't meet every single requirement for the codes billed, we'll take back every single dollar we've paid you for those codes. It's pretty fucked up.
One thing nobody has mentioned yet- research! If a patient is in a trial for an investigational medical device, for instance, the sponsor wants to know every single serial number of every single thing that was involved in the patient's care. Or if it's retrospective research, we do actually look at the nursing notes to see what happened with the patient- it's so much easier to read a free-hand note from nurses or doctors to see what's actually happening with the patient. I know it sucks but it does help us in research. Care plans, etc- now that's a lot of b.s. charting. But y'all's actual notes? People do read them and they are incredibly helpful. Edit to add- there are many trials that have retrospective consent, i.e, registries. So you may not be aware that the patient is in a trial at the time of the procedure but the information that has entered during a procedure is very helpful.
Quite often when I evaluate an emergency patient I go back to charts: Hmm, what do they usually SpO2? Is this a low BP patient? Weight for the CT?
If doing ward duty, immensly useful for seeing improvement.
Thank you.
Good god, what a ridiculous waste of nursing time. Why isn't there a bar code stuck on and let the anesthesia staff just scan it in?
This info is absolutely used for legal purposes as well as infection control.
We had to do a central line and foley audit every night if we had a patient who had them when I worked med surg. They expected it to be completed before 2300.
Audits and lawsuits. In that order. Whenever a chart gets audited, there’s a MAC reviewer out there looking at everything trying to figure out how to deny.
For one admission I have to complete 10 pieces of online work and then another 8 paper. It's a joke and so time consuming. They're just there to prove we are doing what we say we are and it's just ridiculous and time wasting.
When I was a hospitalist I had my default EPIC filter set to remove ALL nursing notes. If there was drama overnight I could look at them, but otherwise I didn’t have to see them.
Not a nurse, but where I am in EMS, the serial numbers for our equipment is also documented… given we have less equipment available overall, it’s mostly automatic.
When I download the data from a monitor, its serial number is automatically filled in on my report. I have a dropdown list of our ventilators and pumps too.
I'm assuming all the machine/equipment serial codes are for infection prevention purposes. So if there is an outbreak of something, it can potentially be traced back to a certain probe or machine used. And then others who had the same equipment used in that time period can be monitored.
If we gotta chart it, the least the admin could do is to give it a scannable barcode.
I gotta vent on this....
Our jobs are seriously so overburdened with the amount of inane documentation that is required. The thing that pisses me off is that higher ups are always adding more required documentation, never taking anything off our plates.
I have ADHD and I hate charting with the fire of a million suns. It's so hard for me to sit down and do it because I would rather be doing things for my patients (and there are plenty of things to do!). Since I transitioned to ICU it's gotten so much harder bc I have all this hourly documentation now in addition to having to chart more frequent assessments.
Rant over. I get why we have to chart most things, especially quantifiable things that other providers actually use in their decision making. It's really just the utterly pointless things like care plans and fall assessments that grind my gears.
The real answer is nobody does. They will do audits, pull a few charts, and if it's missing you are reprimanded. Unless a chart is audited or has gone to legal, literally nobody reads that information. It is incredibly soul-sucking.
It's to waste everyone's time so patient care suffers and admin can make more money from all the inefficiencies and mistakes from having less time to take care of pts.
Not a nurse, but part of the admin that lectures nurses about some of the data entry. A lot of the information that I deal with is for other nurses, care planning helps track a history of what works and doesn't work with the patient. It is as detailed as the person writing it puts in and can help answer questions that a float or someone might have in working with that pt.
It also tracks pt behaviour and that is part of what I have to hammer into the staff. When pts exhibit violent behaviour, the care plan turns into a paper trail of what the pt was doing, what might have triggered it, and what can calm it down. It can quickly turn into a legal paper trail when the pt is particularly agressive/violent and that history is needed to move the pt to a different facility or to change security measures.
Earlier this year there was a pt that was bounced out of 2 other facilities and ended up on one of the wards in my facility and this pt habitually terrorized the nursing staff to the point of most of them quitting that ward. Problem is that they were verbally reporting the issues between each other, and while the admin knew of the problems, without the paper trail they were having continuous problems trying to have the pt moved to a more proper facility. The pts doctors refused to move the pt out of concern of care, but they also didn't know the full extent of the problem the pt was causing as the information in the charts, etc didn't have any of that crucial information. The pt was only moved after they attacked a security guard with a weapon, then assaulted a responding police officer.
Yes it's tedious, but put in your damn notes.
But isn't that the point, though? The message shouldn't be 'put in your damn notes,'--it should be to write something meaningful. If you take that violent patient and fill his chart with all these nursing plan of care notes that say "patient educated on the use of call light" and "mobility progressing" because the nurses don't want to be penalized, then you have done the situation a disservice. Maybe instead of that, the right thing to do is have the nurse dictate a three sentence shift summary in plain English, i.e. "I saw the patient behave violently toward staff," none of this "This writer witnessed..." crap.
In addition to the infection outbreak concerns (which are probably the biggest reason), I’ll also note that working in clinical research, knowing the machines used to collect data, in order to confirm they’ve been calibrated and maintained properly is very important, in order to confirm the measurements are valid and can be trusted.
And clinical trials are often run using the same clinical equipment used on non-trial subjects.
As someone who went from bedside nursing (MA) to manufacturing quality control and now back to medical school. The requirements and expectations for documentation are vastly different and driven by different regulations. This comment is probably off-topic, but I was grilled on my documentation (down to what pen I used) in manufacturing so much more than I ever was in medicine.
Yes, you're right. It is insane.
As a circulator I was told to document the serial numbers on the surgery equipment used in case something goes ary, for example, if the patient gets a burn from a malfunctioning Bair Hugger, bio med needs to be able to identify exactly which Bair Hugger was used so it can be pulled from the OR and be repaired. But I agree with you, the serial number charting is a bit overboard.
I have no idea what the purpose of the RN "plan of care" notes are in Epic. Never seems to affect anything. I'm sure they hate having to spend time entering them.
Trust me, we hate them. Joint commission has decided that we have to document plan of care in some way and we get in trouble when we don’t
I'm sorry y'all have to do that. They're fucking useless, make searching for real information harder, and are a time-suck.
They’re embarrassing. We can’t write them really - we just click stupid boxes and it autogenerates like we don’t actually have anything useful to say and it reinforces how useless and pathetic our “notes” are to the real professionals. No one reads them because they’re useless but subconsciously it reinforces everyday when you skip over it that nursing’s intellectual contribution is useless.
I really wish they didn't even show up in the progress note tab, exile them to flowsheets or something. Because they're not progress notes. I wish nurses had the time and bandwidth to put in a real, brief shift summary progress note but there's so much other clinical and admin BS they dump on y'all.
But flowsheets is where we spill the tea. Our real notes live there.
This. My time is too valuable for double charting. My note 95% of the time is just a mention that I discussed xyz abnormal findings/condition changes with the doc to cover my butt.
My last facility used to get on my case because I never wrote any nurse's notes unless something exceptional occurred. Everything else was charted in the flowsheets. I'm not wasting my time to say the same thing twice. Fuck off, admin.
I also report by exception where I work, I couldn’t imagine doing it any other way. Why would anyone expect a progress note from my pt if all they did was sleep for 8 hours? I’ll document that in the flow sheet but I’m not about to write a paragraph about it.
I have an MD only filter for the progress notes tab that is on by default. If I need to see something else, I have the option to uncheck it
That does also hide PT/OT and CM notes too though (but yes I also do that)
Everywhere I’ve ever worked nurses chart the real info in flow sheets with little comments added to the spreadsheet. It has the perk of being just about impossible for patients to access via MyChart. I agree a 3 sentence narrative note of each shift would be helpful but I wouldn’t want to clog up the notes section with it.
Worth putting IMO, especially if something actually happened, but TBH even a "BM x 1 o/n" would be helpful since flowsheets suck to get to and read from our side in our build of epic.
The issue is it’s difficult for you all to see the flow sheets, not that we aren’t also writing notes. Like wtf is the point of us even documenting our assessments if nobody else can even see them?
Well and that flowsheets are not exactly human-friendly for anything but data. Text assessments, if you can even *find* them are much more annoying to use in flowsheets IME
I’d much rather put in a brief summary note of the shift…it’d actually represent what happened during the shift instead of just a bunch of BS.
Our epic has a separate category for plan of care vs progress notes, so they're easier to filter out.
Wish ours did lol, I can filter it but the same filter also catches a lot of actually useful notes like PT OT, case management/SW, pharmacy etc.
Yes, I remember the good old days, not so long ago, when the overnight RN note was ridiculously useful. As a resident, pre rounding, I could always fine a line or two in the binder like "patient a little nauseated after dinner, slept well, woke up at 3am to void, fell back asleep easily." Like, that's exactly what I needed to know about the night.
You’ve articulated my feelings perfectly - I *hate* reading other nurses’ documentation, and this is why. It’s cringe-inducing to go from the concise, medically-relevant physician notes to, “call light within reach, patient denies needs, will continue to monitor”-type bullshit. I chart the bare minimum and only include notes when I have something relevant to add, chart auditors be damned (kind of).
Nursing contribution is not at all useless!! I absolutely need to know what nurses are thinking and value your opinion. Skipping over the “care plan” fluff note doesn’t make me think nurses are dumb … but I do think the person that decided that nurses need to write that note is dumb.
Everyone knows they’re useless. So they just make them as quick to mindlessly check through as possible. But it makes the ivory tower academics feel like all their hard work “elevating the profession” with nursing diagnoses and shit has a point.
I'm in quality and work closely with risk. We do read them if and when we have a case that needs review or when DOH or TJC show up and ask to pull random charts. I specialize in Behavioral health at my facility. The amount of BS I see in charts is terrible. They claim the patient is clear and then I see the patient back within 72 hours. Our readmission rate is good awful, but I'm told HBIPS is more important. Seriously.
Patient meeting mobility goals Patient fall risk precautions discussed Maury on in patient room -- Like, what the fuck are we doing. This just isn't useful documentation. If documentation isn't useful, then it needs to go. Enough is enough, for fuck's sake.
THANK YOU. And progressing? I was called into an office for putting in my care plan that we weren’t meeting the goal of the patient remaining free from infection because they got VAP. I was told I could only write progressing because things are either progressing forwards or progressing backwards and we don’t need to specify which… what is the point?
that is some grade-a doublespeak there
It's useful if they had a fall because then we can claim they were discussed with the patient and you likey have a fall risk established. As for for the TV that's obsessive, but it does establish the time you made a round. That's exactly how risk and quality see that information.
But here's a question: if the "Plan of Cares" are robotic, non-specific, and ludicrously inappropriate to the situation, how does that acquit the institution from a risk management standpoint? For example, if a nurse documents in the Plan of Care that their GCS 3 comatose patient received education about the use of the call light because they've been directed to do so for every patient at the risk of being penalized in some way, how does that add anything of value? I would argue that bad documentation is more of a liability in some cases than no documentation.
I mean if they actually documented that they did that with a comatose patient then technically they documented incorrectly. A proper EMR would allow the staff member to document the patient is unable to take directions.
I couldn't agree more. Other HCPs could actually get useful info from our notes if they didn't automatically ignore them by rote due to the nonsense care plan notes.
Nursing's intellectual contribution is anything but useless, but it ***is*** highly ephemeral.
You can filter them out pretty easily iirc
Of course. Sorry that you have to waste time doing that!
Yes the auto-generated stuff is useless, but the stuff nurses manually put in that have actual information about the patient is extremely useful most of the time. I'm always grateful when the RN puts more into the note than the auto-generated stuff.
To my knowledge, this is a DNV/JCAHO requirement and we hate it as much as you do. Nursing care plans are truly useless.
PROGRESSING
Care Plans are infinite. Always Progressing.
"Goals today: get better, but stated in a paragraph of blown in text" I don't blame the RN for these, but as a resident I would click on them always hoping for relevant info. But finding... nothing.
Patient intubated , anoxic brain injury Nursing plan of care subsection ( auto populated) Knowledge deficit: progressing.
Progressing towards the vegetable garden
I was just talking about "progressing to funeral home" yesterday
I was once told that the JC will check this in their chart audits, but I have no idea if it's true. We do hate it. So much.
Sounds like notes to justify someone else’s job
ding ding ding
Actually, they do look at these care plans. Source: I was a chart auditor.
Great. What do they do with them? Are they useful in some way? I'm not trying to be snarky. Really, if they have a helpful purpose, I genuinely want to know.
"yup, note was written"
As far as I know at my hospital, they just look to see it was completed each shift. Everyone knows they’re just for compliance at our hospital. Nobody really cares how they’re filled out, just that they’re done to a certain minimum standard.
Patient is a vent dependent high c spine quadriplegic Goal: wean from mechanical vent Plan: ONGOING Are you about to work some miracles here?
Honestly, we RNs don't know what they're for either. We just know that we are required to do them. I literally throw it in at the end of my shift just to have it done. It does nothing but take time from me.
Thank you. I ask that question every day as I’m typing them up for no one to read. Complete waste of time.
Do y'all have the nursing notes that just say "Wiped down all high-touch surfaces including IV pole, computer keyboard..."? Who decided that basic housekeeping needs to be part of the medical record?
We don’t do that, but we do have to chart in the flow sheet that we gave report to the next shift, which is pretty ridiculous as we always give report to the next shift. We also get audited and talked to if we don’t hit the “disinfected meter” comment every time we take a blood sugar. So it’s not a huge leap to see some admin encouraging this with some big “if it wasn’t documented it wasn’t done energy.” (Ofc, when there’s no housekeeping staff to do regular room cleanings…that of course is not documented anywhere).
I need to figure out if there's a way to auto-hide these in Epic. That would be a big improvement.
You can make a filter that only shows you notes written by an attending physician/resident/NP/PA/student/pharmacist or such. I have one set up in every iteration of epic I’ve used. That said, it does also filter out things like telephone notes from the MA and whatnot, so I don’t leave it on all the time. Just assists with chart review.
I wanted to do that, but some RN notes are important. RNs are can be the first Epic documentation that someone is decompensating. Or when something actually occurs overnight that needs documentation. I want to see that stuff. Not the stupid fucking care plan.
What's even more embarrassing is the existence of the [NANDA Nursing Diagnoses](https://www.ncbi.nlm.nih.gov/books/NBK591814/). Yes, we have been formally empowered to "diagnose" conditions...spoiler alert, they're mostly vague "at risk for" bullshit.
I've been critical of this since nursing school. Some nurses take offense, but they're pointless to me. And also embarrassing. All the time we spent in nursing school regurgitating that crap could have been spent on learning more about disease processes, procedures, medications, and hands-on skills.
My all-time favorite NANDA diagnosis is "disturbed energy field". DISTURBED ENERGY FIELD. and the interventions for it are laying on of hands or whatever by a nurse with appropriate energy field training. Like, reiki or what have you. ...NANDA diagnoses are fucking hilarious.
"sending patient good vibes" Plan of Care complete. Nursing Dx are cringe.
"discussed bad vibes with patient, will continue to monitor."
Yes!
I graduated in 1995, so things were a little different then, but not hugely. One of our last classes was a critical care class, focused on learning higher-level disease processes and nursing care. Overall good class. We each had to do a presentation on something for class. For example, one student talked about low molecular weight heparin, which was relatively new at the time. But we had one student...best way to describe her is that if she'd been alive in the 1700s, they'd have burned her as a witch. Her presentation was on "therapeutic touch". I'm thinking ok, massage therapy - not really critical care, but ok. The teacher volunteers to be her subject. I shit you not, student/witch proceeds to shake off her hands to "dispel any negative energies"; she then runs her hands over the instructor. about 2-3 inches over her skin. So nope, not massage, just Reiki bullshit. Worst part was, the instructor went along with it. I lost a lot of faith in my profession that day.
So you can fire the nurse if they don’t do them. Nurse charting is all about creating unsustainable awork loads, so when an eventual error occurs, admin can scrutinize the charting, find one slip up, and blame the nurse for the error. Ignoring the systems issues
Damn. This is what healthcare has become across the board
"oh, see. i looked over your charting and even though you spent 6 hours keeping confused grandpa's face from meeting the floor, you charted mobility as a 2 at the start of the shift, but do you think it could be a 1 instead? Also, I don't see any turns documented"
I don’t do them. Am I supposed to? Yes. Has my manager ever mentioned the fact that I don’t in my quarterly chart audit? No. They clutter the notes section, which is generally the only useful section in the whole chart and imo make us look infantile. I refuse
I do them but I don’t make them a note. In epic if you just hit close it will chart them as done. No note needed. I’m only making notes on events or things I want the doc to see that I don’t want to call them about in the middle of the night.
Great tip. I still probably won’t do them unless my boss makes me but I sure as shit won’t autogenerate a note after when I do eventually get called out on it hahaha
Right, we have “documentation reminders” and in order to get them to go away that’s one of the things that needs charted on Q12. I only do it to get rid of the reminder. Half of the care plans aren’t even relevant.
risk for infection goal ongoing discharge education goal ongoing risk for falls goal ongoing
Same. I feel like it just adds clutter to the notes.
I do them at facilities that force me to do them. If a manager doesn't mention it to me, I'll continue to get away with not doing them.
Plan of care: "Will continue to monitor." The end.
“Family notified, nurse to continue to monitor.”
RN plan of care notes are very helpful: if chart review reveals that the nurse is live-blogging about the patient’s non-slip socks, I can tell the patient is stable.
These notes are so fucking stupid. I hate doing them. What a joke.
They are the bane of my existence.
It’s stupid. All a “care plan” is, is a statement identifying a problem or challenge the patient is facing, and the steps we are taking to mitigate that with them. Then we just click to say whether the task/measure accomplished whatever goal we were trying to get to with that measure. It’s just a long way to say “this is a problem. We are trying A, B, and C. The problem is now solved/the problem isn’t solved yet.” Repeat. Just “problem solving.” lol that’s it.
I can answer this! They turn a red exclamation mark into a green check and then I have more green checks!
It's truly the most egregiously pointless, box-clicking JCAHO bs that I can think of. 😡
They are worthless but it only takes about 10 seconds to click the same shit every single day and post it in epic. No one spends any significant amount of time charting those.
Why do nurses have to complete a Falls risk assessment in the NICU? They are babies. They are all Falls risks. And I know this because they all have little "Falls risk" stickers above their incubators so I am not tempted to take them for walks.
Surely some family out there in the ether must have sued a hospital because their 2-day old premie escaped their bed and strolled down to the coffee shop. Edit: On that note, it is truly staggering how strange anecdotal incidents influence hospital policy.
what??? they can’t even hold their own head up.
Why do ED nurses have to do a swallow screen on every patient who gets a head CT? Stroke or r/o stroke, of course! Headache, MVA, and the litany of other reasons people get a head CT, WHY??????
Why do we have to do them on people who are already on thickened liquids at home at baseline. Like hold on just choke on this 4oz bottle of water real quick and then I’ll get you your simply thick nectar packet and you can keep doing what you’ve been doing for the past 5 years
Cause they might be worse. People go from that to NPO.
I’ve never encountered that, and I wouldn’t play.
I’m about 50/50, only because I get sick of getting the passive aggressive Epic messages.
I was once told by a peds nurse that they have to do a whole fall incident report every time a kid falls even if they’re toddlers and fall literally every ten feet
better get these little shits on 4 point restraints immediately
Ha, when I’m placing lines I do restrain them in a Y like I am crucifying them. Always makes me chuckle.
I didn’t think the information gets reviewed routinely until one day I got a random email from someone in Infection Control that wanted me to look into a particular scope that’s been documented in several patient’s charts and they all got this rare bug (can’t remember the details, it was years ago).
We had a similar thing with some weird yeast infection some inpatient got and it was traced back to a Hamilton vent.
2014 - still have nightmares from that.
That sort of information can be useful to infection control for outbreak investigations.
Or to track issues with equipment, manage manufacturer recalls, look for trends with all sorts of shit. I just moved into Risk Management and the depth of the information is overwhelming, but I’ve already seen how it comes in handy A LOT for improving processes and catching potential patient harm. It’s wild.
I could potentially see that with an anesthesia machine vent or a probe, since those have direct contact with the patient, but stuff like the computer and echo machine don't make a lot of sense.
We traced a Stenotrophomonas outbreak to a portable ultrasound machine using serial numbers from charts. We backtracked to see if our infected patients had the same procedure done and if they had a unit in common. Sure enough, they did. We cultured it and found the bug on the tray where people leave their pens. It sequenced out as the same as our outbreak strain. We took the unit out of service, cleaned the hell out of it, and haven't seen an unusual number of that organism since. It still pops up from time to time, but it does show up randomly.
They all move around the hospital from patient to patient and are a potential reservoir for MDR organisms. They may not make direct contact with a patient, but the doctors, nurses, and techs to touch them do. And, such equipment is often difficult, if not impossible, to sterilize. Can't throw your echo machine into the autoclave (more than once)
>but stuff like the computer and echo machine don't make a lot of sense. Unless you want to track potential software/hardware glitches. Any computer can fail or give a bad reading.
Surgical services can track outbreak pertaining to a specific scope like this. Happened in a local endo department and we heard all about it at our staff meeting, then had to double down on scope washing practice.
Usually? Nobody. When something goes sideways and the patient tries to sue the hospital? Then the lawyers will read them. In terms of actual patient care decisions, they're almost never useful. Which is sad, because nurses know a LOT about what's going on with the patients each day and we've buried their useful input in a mile high pile of garbage.
Amen! Wish there was a way to hide the pointless button clicking stuff so providers could find the useful stuff easier.
A family member of a Hospice pt. sued a hospital I worked at, alleging that the patient's PCA pump malfunctioned and bolused her, causing her death. Obviously, this was not the case, and it was 100% the cancer that killed her. BUT, this lawsuit was the reason our unit had to write down the serial number of every pump a patient utilized.
That really sucks. The worst part is the plaintiff could claim any individual part was responsible and make it even more difficult to disprove--for example, they could claim it was a bad channel on an Alaris pump that kept alarming, but how could you possibly track that down to prove/disprove? AFAIK the channels don't have individual serial numbers, and the channels float around them entire hospital.
Oh. But just this past year our hospital tweaked the workflow so that nurses do in fact have to scan the med, the patient AND now the channel (that has a serial number and corresponding QR code sticker on its face), all with hard stops in between to click something/confirm something, so you go back and forth between the computer and the patient bedside 3 times before it’s “charted”. Efficiency!
Ugh. And then the "Why hasn't the levo been hung yet?" or the write-ups for overriding bar code scans.
Oh, interesting. You're right. Fortunately (?) this was with the pumps we had pre-Alaris. So the plaintiff lost the suit, BUT, the fear lives on.
As a OR RN my dream is to reduce the time charting those damn serial numbers on every piece of equipment. Every new device seems to automatically get added to the list of things we chart, senseless. At least we should be able to scan the serial number barcode stickers and have it auto populate the chart.
I can’t even imagine doing this every shift on the 5-10 pumps I use for each patient…
This. I was a paralegal before I became a nurse. It's to defend us all from the occasional lawsuits. There is like one huge multimillion dollar settlement behind each piece of ridiculous minutia.
If I am in hospice, I am hoping that a large bolus is the way I go.
Im taking over as ICU director soon, and step one is going to be an audit of nursing documentation requirements. Even before doing it, I know of multiple redudancies/overlapping documentation requirements. Every initiative within the hospital seems to have "oh the nurses can do that!" as a solution and its burning everyone out. I cant get over admin scratching their heads over why over 50% of our ICU nurses have <2 years experience... So the short answer is...almost noone reviews it. If they do, its almost never reviewed for anything clinically relevant
Good luck. I feel like there are a lot of clipboard RNs who justify their whole jobs by creating more and more useless audits for us to document. And someone is monitoring some of them (though it seems to rotate which ones they’re looking at), as we get nastygrams on occasion if we forget to check 1/10,000 boxes we have to check every shift.
Oh I know it'll be a fight. I've brought it up before and the answer I got was "yes we do keep track of everything they have to do." No one could provide me with that document so far. I suppose we will see🤷♂️ I gotta try and do something, I'm sick of losing all my badass nurses
Good luck, 90% of the charting we do is to fulfill JHCAO requirements and would probably be pretty hard to get rid of. During Covid they temporarily got rid of the extra charting at my hospital and it was so nice not having an a hours worth of straight charting to do in the beginning of each shift.
I’m curious how much is actually JC requirements, vs some random hospital admin’s interpretation of JC requirements.
Fighting the good fight. Please keep us updated how it goes. I feel bad for our nurses that have to do all this charting and would love to see how someone else addresses this.
Imagine what could happen if we could actually focus our time and effort on taking care of patients! -RN who was told during orientation that I spent too much time with my patients and needed to prioritize charting.
The appropriate response to that statement will always be “patient care comes first”.
I'm so glad my preceptor was the exact opposite of that. But it might have been bad that we both felt the same way and I never developed the care for charting past the bare minimum.
As an incoming RN (current student). THANK YOU <3
> Every initiative within the hospital seems to have "oh the nurses can do that!" I have to laugh at SCCM for that. SCCM has a huge ICU liberation protocol that has some good evidence for it, even if the actual recommendations are rather underwhelming. They've also promoted integration with Epic for documenting the A-F bundle. I don't care whether a nurse documents, I care that they do it. It's too simple to just pencil whip the assessments (who actually does a proper CAM assessment after all). So why would I make them devote more time to the computer?
"If you didn't chart it, it didn't happen" is the annoying mantra of nursing admin. Meanwhile a good half of things charted by my peers definitely didn't happen. I'm looking at you, coworker who charted that they gave their patient a bath an hour into the shift. Or charted an auscultation assessment for every single lung field on an ECMO patient that they only reposition for the most dire bed-soiling circumstances.
You have my sincere gratitude for the war you are about to wage on nursing's behalf.
you’re doing the Lord’s work
If I worked there, I would throw you a pizza party for this.
I love you. It feels like the hospital falls all over themselves to satisfy regulatory requirements but never thinks about how to do it in the most efficient/least annoying way….and certainly never goes back to eliminate things that are no longer necessary.
In terms of anal, law firms have used e-discovery methods for years, and of course they are going to be using AI tools as well (with, presumably, human checks after a few scandalous AI flops in front of judges). One day someone is going to sue someone, maybe over the reliability of the device, maybe in patent litigation, somewhere. At times I have been bemused by all the numbers we use, though, and although I know the mathematical universe is absolutely infinite part of me wants to think it will all get filled up and explode. EMR ID numbers, serial numbers, case numbers, all the gibberish that is on those labels on electronic devices of any kind, MAC addresses, IP addresses. It is, of course, being stored somewhere, and more data one way or another to try to protect that data (which is bound to decay over time), and all of it is in server farms, preferably area where land is cheap but there's plenty of access to the electrical grid, and all of it making the planet hotter and hotter and hotter.
> In terms of anal Hmm
Got my attention
When we had paper charts back in the ice ages I used to review nursing notes. They would write relevant info and the notes would give a picture of what happened with patient overnight. Now with EMR I don’t even know where all their documentation goes. I don’t think they write notes as much anymore bc they’ve got to click so many buttons, who’s got the time?
A lot of it goes into Flowsheets which are usually not readily accessible or else present the information in non-human friendly ways.
The flow sheets make life so hard. I don’t even know what providers can see of the documentation I record. All of my head to toe assessments are in flow sheets, and I’m pretty sure providers can’t or don’t know how to access them. I also work in surgical stepdown & we follow ERAS pathway recoveries and providers can’t see all of my painstaking mobility charting, which I know because their notes always say “patient has not ambulated” when I forced them up out of bed to walk at 0300, & for some reason the patients always say they haven’t gotten up. In theory flowsheet documentation for nursing assessments should give you the ability to trend data over time, such as orientation or neurovascular checks, but as far as I know the Epic flavor we use doesn’t have any data visualization tools like that.
Flowsheets are one of those things that you won't find unless you know where to look and you know what you're looking for. For example, let's say I'm preparing for a case in the OR for an inpatient and I want to know what IV lines the patients has. Some implementations of Cerner and EPIC will specifically import that information into my workflow, but for others I have to find a way into the Flowsheet and look at the dressing assessments to see "Oh, this guy has a central line." Finding that section of the Flowsheet takes a spectacular deep dive as there may be other sections labeled for IVs that have no information in them. Sometimes the category in the Flowsheet is not what it claims to be.
LDAs are linked on the front page of the chart for us. Having to dig for that sounds extremely annoying.
I use the flow sheets pretty regularly but it’s like you said - very poorly formatted and also 5 clicks deep in a submenu. I’ll use it if I’m looking for a specific piece of information like nursing neuro exam or CRRT start and stop times. But unless you knew exactly where to look and what the flow sheet was called, you would not be able to find any of that info.
That’s so asinine. What’s the point if not to record data for the providers?? That just means I have to double chart anything important- once in my flowsheets for my required BS and then also write a narrative note for you guys. I can’t even trend a specific item in the flowsheet to see values past the previous 24 hours. Clunky and useless.
And I was specifically told before a JCAHO audit not to put anything in a nursing note that was in flowsheets because it’s double-charting. But I also quickly learned that providers didn’t know how/didn’t have time to look at what I charted in flowsheets, so how else are they going to see a quick summary of relevant things that happened during my shift?
Lawyers.
It's a lot more useful than you'd think. Most good systems let you just scan a barcode on each device, and it actually saves a ton of time in the long run by ensuring all the medical things are serviced at the right time, what supplies are consistently fully utilized to buy additional equipment, occasionally infection prevention if an infection can be tied to a particular piece of equipment, auditing each procedure always has all the correct things available etc etc. This kind of documentation is one of the most effective QC systems we have and it tends to be totally transparent to providers. There are many many many dumb things we do for no reason, documenting what specific equipment is where is not one of them.
> This kind of documentation is one of the most effective QC systems we have and it tends to be totally transparent to providers. I'll remember that the next time the thing I've reported broken for a year gets fixed lol
There's a whole thing called QA nursing. The job of these quality assurance nurses is to go thru our charting and bitch at us when we "aren't titrating every 5 minutes" or "why did you forget to chart your Q2 turns". Honestly if there's any part of nursing that's gonna be replaced by AI it's this.
And if we titrated levo according to the 2 minute interval protocol? Half our patients wouldn’t be here.
For sure. Chat gpt could probably do just as good a job combing through charts and writing nastygram emails as the humans doing it now.
I’m a QA nurse now, after 24 years of bedside. My messages are more like “Hey hate to bother you but you didn’t document the—fill in the blank with whatever joint commission likes to scrutinize—so could you please get it fixed?” I like to think if I can swoop in and get it corrected before the clinical director blows it out of proportion then life goes easier for everyone. I know I’m a pain the ass, but most of the stuff I review I do so because it’s come up in a survey.
I found out some hospital billing is based on reviews of Dr's. Orders, therapists progress notes, from the chart. Wife was in house for 3 nights with anemia. I got itemized bill and she was charged for i.c.u. care. She was never in i.c.u. Also charged for p/t, o/t based on progress notes. No p/t or o.t done. They got pissed when I mentioned Medicare fraud.
Just saw that personally. A patient of mine brought in some of their bills, and it turns out some PT facility they went to twice has been billing them as being seen three times a week for the last six months. They had an order in January for 3x/wk for a month after surgery, but no secondary order as ortho said it was not needed. So now the patient's insurance is suing the PT, using my records and ortho's to document that she was never referred there after January.
That's insane. Considering the amount of garbage copy-pasted macro'd stuff people put in their progress notes, extrapolating billing from that is robbery.
That's cause medicare fraud is no joke. Hanging that OIG referral over their head is a great way to lower your bills.
Fraud is a great word to drop if you want billing departments to take you seriously. I had a surgery that I was ultimately billed zero dollars on bc I caught them upcoding and double billing.
Billing lady told me if you have charges for icu care, all other charges you may have, labs or xray say, those charges are increased just because it's an icu pt.
Wowwww I had no idea
That actually makes some sense, especially for imaging. It’s a lot more work to move an icu patient somewhere, or you have to bring up the portable. A lot of med surg patents you can throw in a wheelchair or they’re coming down in just the bed with maybe one iv and an oxygen tank.
Haha I agree. They record the number on my forced air warming machine, pumps, fluid warmer. No idea where or what purpose it serves.
I assume no one ever reviews it and it's just a decades-long snowball effect of nurse administrators who think "documentation = safety"
Hopefully folks aren't handwriting/typing serial numbers and have the luxury of a barcode scanner. . .
We didn’t when I had to do that in endoscopy. I had to hand type it in. If I was rushed I would take pictures of the packaging to enter it later
The serial numbers are needed in case some funky shit happens and they want to come back and say: oh that’s where the xyz came from! That’s what caused the patient harm. Not the hospital and its practices. It was the machine gone rogue.
On a personal note, I wasn't able to know what happened when my dad died and family is less than helpful, so being able to review the chart, literally hour by hour, has been helpful in giving me understanding and closure. Granted I know how to read a chart. Edit: the records were ordered through proper ROI channels.
Serial numbers are critical for infection prevention investigations, especially contact tracing. Look up the [Olympus endoscope outbreaks from 2014](https://www.latimes.com/business/la-fi-olympus-outbreak-20150302-story.html). That's how the outbreak was traced back to the scopes. We've done several outbreak investigations related to other portable, shared equipment where tracking who it's been used on has been pivotal. Any time we get more than 3 inpatients with an unusual bug, especially if it has the same sensitivity pattern, IP starts scouring charts for commonalities - floors, procedures, staff, equipment.
Because if something bad does happen, a sentinel event, they want to be able to look at any and all variables that may have been involved so they can ensure harm to patients or workers can be prevented. Some info, it's redundant for sure, but some is useful for others who track things like that.
It is valuable info for infection control contract tracing. I can remember a hospital I work at having to contact several neurosurgical patients and let them know they may have been exposed to CJD that was tied back to a particular piece of OR equipment
Pretty much like any charting a doctor does only a few people will ever read it. Billing and Lawyers. And when you definitely know CQI is going to be reading the chart you'll be a bit more thorough.
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I would think its probably in case of a lawsuit or equipment failure or blaming equipment failure theres the serial number of the machine. Everyone wants to sue these days.
Probably can count on one hand how many nursing notes I’ve read in 25 years.
Risk management. Patient had an exam change overnight. Was it documented? No? Whoops.
I’ve noticed so much of this performative bullshit at my hospital. Everyone on the clinical side is tired of it but the MBAs in charge have mandated it so we do it. I highly doubt this stuff is useful in lawsuits anyway and if it is, it shouldn’t make everything more tedious and expensive just to be a solution when the extremely rare lawsuit regarding medical devices comes up.
dude the only time that shit will be reviewed is when the lawyers get involved. so that they can say dr so and so how come you didnt respond when nurse so and so said pt was nonresponsive.
Insurance auditors. We'll request years of medical records at a time, and if your documentation doesn't meet every single requirement for the codes billed, we'll take back every single dollar we've paid you for those codes. It's pretty fucked up.
It's there for the lawyers to review the deterioration and "doctor informed" when patients die.
One thing nobody has mentioned yet- research! If a patient is in a trial for an investigational medical device, for instance, the sponsor wants to know every single serial number of every single thing that was involved in the patient's care. Or if it's retrospective research, we do actually look at the nursing notes to see what happened with the patient- it's so much easier to read a free-hand note from nurses or doctors to see what's actually happening with the patient. I know it sucks but it does help us in research. Care plans, etc- now that's a lot of b.s. charting. But y'all's actual notes? People do read them and they are incredibly helpful. Edit to add- there are many trials that have retrospective consent, i.e, registries. So you may not be aware that the patient is in a trial at the time of the procedure but the information that has entered during a procedure is very helpful.
Quite often when I evaluate an emergency patient I go back to charts: Hmm, what do they usually SpO2? Is this a low BP patient? Weight for the CT? If doing ward duty, immensly useful for seeing improvement. Thank you.
Good god, what a ridiculous waste of nursing time. Why isn't there a bar code stuck on and let the anesthesia staff just scan it in? This info is absolutely used for legal purposes as well as infection control.
And people wonder why I stick to outpatient primary care. 😆
Our management doesn’t even have time to review all our charting themselves and they make us audit each others’ charting from time to time 🫠
I wish nurses would just band together and refuse to do this.
We had to do a central line and foley audit every night if we had a patient who had them when I worked med surg. They expected it to be completed before 2300.
Audits and lawsuits. In that order. Whenever a chart gets audited, there’s a MAC reviewer out there looking at everything trying to figure out how to deny.
For one admission I have to complete 10 pieces of online work and then another 8 paper. It's a joke and so time consuming. They're just there to prove we are doing what we say we are and it's just ridiculous and time wasting.
When I was a hospitalist I had my default EPIC filter set to remove ALL nursing notes. If there was drama overnight I could look at them, but otherwise I didn’t have to see them.
Not a nurse, but where I am in EMS, the serial numbers for our equipment is also documented… given we have less equipment available overall, it’s mostly automatic. When I download the data from a monitor, its serial number is automatically filled in on my report. I have a dropdown list of our ventilators and pumps too.
I'm assuming all the machine/equipment serial codes are for infection prevention purposes. So if there is an outbreak of something, it can potentially be traced back to a certain probe or machine used. And then others who had the same equipment used in that time period can be monitored.
If we gotta chart it, the least the admin could do is to give it a scannable barcode. I gotta vent on this.... Our jobs are seriously so overburdened with the amount of inane documentation that is required. The thing that pisses me off is that higher ups are always adding more required documentation, never taking anything off our plates. I have ADHD and I hate charting with the fire of a million suns. It's so hard for me to sit down and do it because I would rather be doing things for my patients (and there are plenty of things to do!). Since I transitioned to ICU it's gotten so much harder bc I have all this hourly documentation now in addition to having to chart more frequent assessments. Rant over. I get why we have to chart most things, especially quantifiable things that other providers actually use in their decision making. It's really just the utterly pointless things like care plans and fall assessments that grind my gears.
The real answer is nobody does. They will do audits, pull a few charts, and if it's missing you are reprimanded. Unless a chart is audited or has gone to legal, literally nobody reads that information. It is incredibly soul-sucking.
It's to waste everyone's time so patient care suffers and admin can make more money from all the inefficiencies and mistakes from having less time to take care of pts.
Not a nurse, but part of the admin that lectures nurses about some of the data entry. A lot of the information that I deal with is for other nurses, care planning helps track a history of what works and doesn't work with the patient. It is as detailed as the person writing it puts in and can help answer questions that a float or someone might have in working with that pt. It also tracks pt behaviour and that is part of what I have to hammer into the staff. When pts exhibit violent behaviour, the care plan turns into a paper trail of what the pt was doing, what might have triggered it, and what can calm it down. It can quickly turn into a legal paper trail when the pt is particularly agressive/violent and that history is needed to move the pt to a different facility or to change security measures. Earlier this year there was a pt that was bounced out of 2 other facilities and ended up on one of the wards in my facility and this pt habitually terrorized the nursing staff to the point of most of them quitting that ward. Problem is that they were verbally reporting the issues between each other, and while the admin knew of the problems, without the paper trail they were having continuous problems trying to have the pt moved to a more proper facility. The pts doctors refused to move the pt out of concern of care, but they also didn't know the full extent of the problem the pt was causing as the information in the charts, etc didn't have any of that crucial information. The pt was only moved after they attacked a security guard with a weapon, then assaulted a responding police officer. Yes it's tedious, but put in your damn notes.
But isn't that the point, though? The message shouldn't be 'put in your damn notes,'--it should be to write something meaningful. If you take that violent patient and fill his chart with all these nursing plan of care notes that say "patient educated on the use of call light" and "mobility progressing" because the nurses don't want to be penalized, then you have done the situation a disservice. Maybe instead of that, the right thing to do is have the nurse dictate a three sentence shift summary in plain English, i.e. "I saw the patient behave violently toward staff," none of this "This writer witnessed..." crap.
In addition to the infection outbreak concerns (which are probably the biggest reason), I’ll also note that working in clinical research, knowing the machines used to collect data, in order to confirm they’ve been calibrated and maintained properly is very important, in order to confirm the measurements are valid and can be trusted. And clinical trials are often run using the same clinical equipment used on non-trial subjects.
90% of stupid business requirements in the US are because someone sued someone over it in the past.
As someone who went from bedside nursing (MA) to manufacturing quality control and now back to medical school. The requirements and expectations for documentation are vastly different and driven by different regulations. This comment is probably off-topic, but I was grilled on my documentation (down to what pen I used) in manufacturing so much more than I ever was in medicine.
Yes, you're right. It is insane. As a circulator I was told to document the serial numbers on the surgery equipment used in case something goes ary, for example, if the patient gets a burn from a malfunctioning Bair Hugger, bio med needs to be able to identify exactly which Bair Hugger was used so it can be pulled from the OR and be repaired. But I agree with you, the serial number charting is a bit overboard.