When I was working, a good few years ago now, in a busy Intensive Care Unit (ICU) my own, and a lot of other nurses experiences, of the endless charting and computer-entry data was the one of the most challenging aspects of the shift.
Picture the scene. I arrive at work for a 12 hour night shift which was from 20:00 until 08:00 the next morning. Following report whereby a summary of all the patients conditions and care is given I am allocated an extremely critically unwell patient. I arrive at the bedside and the patient, Mrs Jones, a 54 year old lady with septicemia, is what was known in the trade as ‘going off’.
Mrs Jones needed multi-system support. That is to say she was:-
- Intubated and ventilated – Mechanical support of breathing to provide adequate oxygenation
- Requiring Inotropic Support to stabilise her circulatory system and provide adequate blood oxygenation
- On a dialysis machine to support kidney function and remove excess fluids and waste products from the blood.
- Intensive/Invasive monitoring: Arterial line, Central Venous Pressure (CVP) Line and Total Parenteral Nutrition line.
As I arrive at the bedside and the nurse who has been looking after Mrs. Jones hands over, I quickly realise that this lady is very seriously unwell indeed. There is no time at all for looking through the endless charts or logging onto the computer to review her care. We have a crisis situation.
- Blood oxygen levels are dropping: Nursing care involves taking arterial blood to test the blood gases and adjusting ventilation accordingly. Urgent suctioning and bagging is also required.
- Blood pressure dropping, heart rate very high with arrhythmias (Tachycardia) Nursing Actions: Urgent medical advice regarding adjusting the inotrope and vasopressor drugs.
- Dialysis machine: Nursing Action: Change the dialysate fluid bags, empty and measure the large catheter bags of waste products.
- Observations: All the observations need to be recorded hourly on a chart.
- Medications: On top of all this a whole array of intravenous medications need to be prepared, checked and administered.
- General patient Care: Turning and cleaning the patient, who has been incontinent. Mouth care and eye care at least 2 hourly.
Following three intensive hours of high speed crisis-diverting nursing, the patient is finally stabilized.
Often though, if a shift begins like this you tend to be playing ‘catch up‘ for the rest of the night. The hourly charting, care of the dialysis machine and fluids, the blood gases and suctioning, the medications and general care all continue throughout the night shift. With a very critically unwell patient, by the time the continual observations have been charted it is time to start again. As you can well imagine, there is little time for anything else, and often the endless recording interferes with actual patient care.
Following a gruelling 12 hour shift, with two 15 minute breaks and one 30 minute food break, the day nurse appears and bleary-eyed and exhausted I perform the bedside handover. Unfortunately for me, it’s been ‘one of those shifts.’
I would like to point out here that this situation was in no way unusual and also occurs in most hospital areas including Accident and Emergency Units and other wards. It only takes a few unexpected events and literally, all hell breaks loose.
The work does not end there though. Officially it is 8 in the morning, the end of the shift, but due to the busy pace of the night work there is now a lot of computer data to enter and also endless forms and charting. So I find myself in a situation whereby I am sitting down writing a care plan for the patient over 12 hours after the care has been administered. I must fill in what the patient’s condition was on arrival and the care I plan to administer.
I then must list and check endless boxes of what care was given on the computer. This it appears is more for ward auditing and budgeting than for patient care. The irony is that an audit is used to improve the quality of patient care by reviewing all care and implementing better nursing practices.
I must fill in all the blood gas and test results that arrived over night and put all the forms in an evaluation folder. Entering data into the computer can be time consuming due to the endless logging in and out and browsing through duplicate screens.
I need to make all the calculations for the input and output on the fluid balance charts as I only had time to write the actual figures over the course of the shift.
Finally I write an evaluation for the patient and summarize everything that has happened over the shift. Oh yes, nearly forgot have to do a patient dependency score also and a fall risk assessment sheet and a pressure sore score.
Almost 2 hours late from work I am finally done.
Benefits of Charting
Whilst there are issues with more time being spent on the charts than on the patient, accurate documentation remains an essential and legal requirement and here’s why:-
The Human Rights Act of 1998 and the Data Protection Act of the same year meant that patients have the right to access their medical records. Furthermore, with more and more information readily available over the internet, patients are increasingly likely to make complaints regarding their care and treatment whilst in hospital.
Good documentation is also essential to the whole communication process of the team. Accurate Recording and reporting treatment and care is essential for the well being of the patient.
Nurse Megan’s Top Tips for Good Charting
• Be as accurate as possible. Do not state, for example, ‘blood pressure low‘ but rather, write BP 90/50. Be specific about values and amounts.
• Keep the information charted objective. Chart only what you actually directly observe. Do not make assumptions, fill in any missing information or give your own opinions.
• Chart as soon as possible after care is given. Never chart any care or medications before you have given them. Try whenever possible, to chart information immediately after the care or medication has been administered.(NB: As we have seen this often works much better in theory than in practice).
• Write clearly and legibly. This is a big one for the doctors! Drug errors are much more likely to occur if the prescription is barely readable. Never guess what it says always phone a doctor and check.
• Use only approved abbreviations. Abbreviations are commonly used in hospitals but do take care. BP for blood pressure is more than acceptable but if an abbreviation has more than one meaning then spell out the full word.
How much Charting is too much?
The amount of paperwork, form filling and computer data entry has increased dramatically since 2008. Whilst we understand the need for accurate documentation the burning question remains, has the form filling gone too far?
In the UK an average 17.3% of all the hours worked by nurses is spent on non-essential paperwork. Furthermore 81% of nurses, working in all types of wards and units, stated that non-essential form filling and data entry directly interfered with bedside patient care.
Dr Peter Carter summarizes nicely when he stated that,
“…a shocking amount of a nurse’s time is being wasted on unnecessary paperwork and bureaucracy. Yes, some paperwork is essential and nurses will continue to do this, but patients want their nurses by their bedside, not ticking boxes.”
What about Computerized Charting?
With the advent of computerized charting and documentation, the problems facing many paper-shuffling nurses were supposed to be relieved but there have been more than a few problems here too.
In facilities where Electronic Health Records (EHR’s) have been introduced the same problems and some new ones too have emerged.
Many nurses have reported that documentation is now taking even longer. One nurse claimed that, on average HER’s have added 3 hours to the average shift. Here are some of the main disadvantages:-
- Endless logging in and logging out of computers
- An increase in mandatory documentation forms
- Having to log in nursing care and treatments that were not done
- Slow, difficult computer systems
- Queues of staff at the end of the shift waiting to write up their data (no change there then)
- Privacy Protection Issues
- Potential Data Loss: One crashed computer and the records and time spent retrieving them only adds to costs. This sometimes leads to a situation whereby nurses are entering all the data into a computer and keeping paper records too – double the time!
- Drop-down menus and check boxes that are impersonal and sometimes lack the options for specific situations that previously nurses would have written in their own words.