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I HAVE HAD IT!!

I had no idea, as a young impressionable eager nursing student, that I would eventually be SO inundated with paperwork once I became a nurse.

It is truly unbelievable how much crap we have to fill out and keep track of. I have no idea why this can’t be streamlined somehow, but then again, it may be impossible by this point. I just thought you might like to have an insight into the amount of utter banal paperwork I must keep track of. Keep in mind that any particular patient may have only some of these. But some of them actually have ALL of them.

First there’s the ABG flowsheet. It’s where we write down the patient’s ABG’s so we can keep an eye on trends at a glance. Never mind that every single day at 4pm the printer spits out up-to-date lab sheets on every lab test the patient has had. We need to have this one particular one for ABG’s.

Then there’s the blood glucose flowsheets. Even when the patient isn’t diabetic, if they are started on TPN, they have to have twice daily blood sugar checks. And you guessed it… there’s a separate sheet for that. If the patient is a diabetic and receiving insulin, it’s a good sheet to have to keep track of what the patient’s blood sugars are and if the amount of insulin is working.

Of course there is our “vitals” flowsheet where we write down vital signs (as often as every minute sometimes), keep track of titrating drugs, add up our Intake/Outputs, chart unscheduled meds. This one is most important and every single patient has one.

Next is the Blood Transfusion Consent form, along with Blood Transfusion Fact Sheet. Before, we just gave blood to whoever needed it, with a verbal consent. Now we have to get it in writing.

Let’s not forget the Advance Directive sheet. If someone comes in with no Advance Directive, we have to give them an information sheet describing what one is, and if they want to sign one right then and there, by golly there is yet ANOTHER sheet to give them to do that. Even if they don’t want an Advance Directive, we still, by law, must give them an information sheet.

The newest sheet is the Flu Vaccine consent. It comes bundled with 2 different flu vaccine info sheets, and another checklist to complete to determine if the patient is eligible to get the vaccine. Thank God that one’s only seasonal.

There’s the sheet we use to mount EKG strips to.

There’s also an admission sheet. We have to fill this out at the bedside, then go back to the computer and enter in all the information. As a side rant, after we’re done filling in the patient’s entire health history (never mind if someone’s already done it on a previous admission… this computer system is over 30 years old and apparently didn’t take that into account… we have to fill in EVERY blank for EVERY admission), we have to do a “teaching assessment” where we write what we think the patient’s knowledge of their current condition is, the steps we are going to take to educate him, and THEN we have to document somewhere that we’ve actually done the teaching. And don’t forget to include that you taught the family as well. THEN we have to come up with a “nursing care plan” whereas we come up with “problem statements”, desired outcome, deadline, and interventions that we will take to fix the “problem.” More on nursing care plans in another post. I hate nursing care plans.

Then there is the “basic care needs” that we must fill out, clicking this and that to add to the Master Care Plan that the patient has an NG tube, ET tube, ostomy, what lines they have, when those lines were put in, when the tubing changes were on what drips, right down to how much help they need bathing themselves, for God’s sake. Basic Care Needs are pointless as well. No one ever looks at them on the care plan, and they’re hardly ever updated. Go look at the patient! Don’t rely on a stupid care plan to tell you whether the patient has a foley catheter. I hate updating the tubing changes, because the tubing is always labeled with the date and time that it was hung. Charting it AGAIN is redundant.

If you make a med error, or even if your patient’s dentures are lost, or really for anything under the sun, you have to fill out a Quality Assurance form. Those are fun.

My least favorite is the restraint sheet. Many of our patients have restraints, usually to keep them from pulling out various tubes and wires whilst they are in their drug-induced haze. Restraints are a really huge issue with The Powers That Be. The restraint flowsheet is total bunk. You just initial boxes saying that you’ve checked the restraints to make sure they aren’t too tight, that you’ve offered food/drink every 2 hours, that you’ve asked the patient if they need the bathroom every 2 hours, that you’ve provided range of motion exercises and untied the restraints every 2 hours, and oh by the way, why exactly ARE you using restraints? And have you told the patient and family why? And have you made a f#@$#@$ing nursing diagnosis problem statement about it?? Thing is, our patients that are restrained are already receiving tube feedings, and have numerous tubes to take care of potty concerns, and basically have no clue about anything at all. I’m not saying those things aren’t important; they are. But they aren’t always applicable. And I feel that it’s pointless, because sometimes you just initial the box even when you haven’t had time to actually DO all of that.

Who could forget the wound care sheet? Whenever the patient develops or presents with any kind of wound, be it surgical, pressure ulcer, vascular, whatever, we have to take a Polaroid picture of it (using the little stick-on ruler papers for scale) and fill out a wound sheet, where we circle the area on the body that the wound is located, the measurements, what it looks like, smells like, what treatment we’re doing for it, and any other comment we care to contribute. One wound sheet for each wound. And the Polaroid (which may or may not turn out) gets taped to the Progress Notes for the docs to ignore.

Did I mention that there is a consent form for the patient to sign giving us permission to take a picture of their wound?

The lastest sheet that’s come out is going to be a doozy. Every charge nurse on every 8 hour shift is going to have to fill out this legal-paper-sized form saying what nurse has what patient, when the patient was transferred out if applicable, when a patient was admitted, when the nurse took her break, blah blah blah. I think these sheets are supposed to protect us due to the law that starts on January 1st, but come on. These stupid sheets need to be kept for 3 YEARS in case there’s ever a question that the new nurse:patient ratios weren’t followed to the letter. For my unit ALONE, that’s 1,095 pieces of paper PER YEAR that will have to be filed. Add in all the other units (at least 8 others) and you’ve killed a small forest with having to file away 8,760 pieces of paper. At the end of 3 years, we’ve accumulated 26,280 papers.

For the love of God and cotton candy, this has all gone WAY out of control. Everytime Joint Commission (you’ll notice I’ve not provided a definition for these jerk-offs… I wouldn’t know where to begin) gets their knickers in a knot over something, we seem to have to add yet another flowsheet to cover our asses. Basically, when I get a new admission, it is entirely possible that I will have to utilize every single one of these sheets on them. (Let’s not forget the OR checklist and consent forms) in addition to starting IV’s, mixing medications, inserting various tubes, monitoring urine output, vasoactive drips, etc, writing down vitals, tagging IV tubing, teaching the patient and family about everything under the sun, drawing labs, calling docs, IT HAS BECOME MADNESS.

I swear I spent JUST as much time filling out paperwork and computer crap as I did at my patient’s bedsides tonight. I’d be surprised that anyone actually read this entire thing. Filling out all this baloney is Tedious with a capital T. I just can’t wait to see what paper they throw at us next.

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Comments

It didn’t always use to be that way. When my mother returned to nursing after a long hiatus her first question was “What happened to NURSING a patient. Do we not to any care anymore? All I do is fill out paperwork and pass orders along to LPNs.”

And let’s not forget the anticoagulant sheet, the medication administration sheet, the surgical identification sheet (not to be confused with the surgical consent form, the pre-surgical checklist, or the pre-surgical anesthesia questionaire checklist)…

The list seems endless, and nobody seems to give a shit.

Nursing administrators that don’t want to do patient care have to justify their job some how. Why not a paper that lets them know how long you were in the john while another nurse watched your patients?
Better yet do like the Mayo clinic. Wear a badge that automatically records how long you took to take a piss. No really, I couldn’t make that up.

Thank you Joint Commission!!!

Fortunately, my employer has combined several of the standard flowsheets into one great big one. Including restraints. Oh glory be! Sigh.

You should see me when I have to give IVIG or Albumin. Extra paper out the hind end.

I’m beginning to think that JCAHO is tied in with the logging industry.

Technology will save the day — in the long run. One day every nurse will use a wearable computer which responds to simple voice commands and logs all important events centrally.

Wow, I had no idea there was that much paperwork. I always wondered why I had to give my entire medical history every single time I was admitted, which for a while there was like every 3 weeks. I’m like “I was just here!” Now I know it’s as frustrating for the nurses as it is for the patients.

I left home health nursing because I got so sick and tired of all the paperwork. Between JCAHO and Medicare, it was ridiculous. The people who come up with all the JCAHO stuff are so far removed from the real clinical world they don’t have a clue. In Workers Comp case managment there is paperwork but nothing like home health. But we have URAC now, so I’m anticipating it getting worse.

Don’t forget all the paperwork needed to transfer the patient. Including the copy of the chart needed as well.

Here’s some feedback by a medical records person (currently a coder.) I feel your pain/ hear your anguish/ sympathise with what you’re gong through. It sounds like your facility has really dropped the ball in terms of updating your documentation systems. Like it or not, the name of the game is reimbursement, which depends on documenting what you’ve done. Without a clear and coherent record of what has been done with each patient, the hospital can’t defend itself (and you) from frivolous lawsuits, good data can’t be acquired for records, and proper reimbursement won’t happen. Sadly, the name of the game is reimbursement, and your salaries (in the end) come from the billing department. The best thing that you can do is work with your Medical Records department (under whatever name it appears) and your Information Technology people. They need to know what the bedside users need, and they may need to hear it several times, and at increasing volumes.
This can be done, and it will work for the patients and for the staff, but it will take a determined effort by everybody involved to overcome the resistance from money and habit. Good luck to you, and I’m glad to hear that you’re fighting for your patients!

All of the comments resonate with me (when I was in my RN program, a nursing assessment = VS, wgt, allergies & ‘do you want communion?’ – so things have changed. But I wonder what documentation can be eliminated? should you document what you assess? should you do less assessment so you don’t have so much to document? is the fact patients are sicker/more acute a reason why there’s so much to document? Would be interested to hear your perspective.

I’m in home health. 4 years. At this point, I am anticipating the paperwork that QI is going to start using, based on what they’re phasing out, or new requirements. I guess it’s a game right now, that I play to entertain myself–see how complete a picture the last nurse has left that saw the patient, and if I can paint a more complete portrait. What a dork I am. And when I work a per diem shift at the hospital, I am amazed at how easy the paperwork is. After home health, I have my brain sorted out to fill in the blanks on the right papers based on what I’ve seen from my patients.

I guess I am preaching to the converted but I do agree that JCAHO is an organization that has no clear relevance to patient care. The only people who really care about it are hospital administrators (and with the support of a group like that, it must be really important, right?). If JCAHO were really interested in improving patient care, why doesn’t it take a stand on issues such as nursing staffing or limiting hours for interns (see new study from Harvard that says interns working 30+ hours make 36% more mistakes)instead of pushing more paperwork on healthcare workers in the trenches? Because JACHO then would offend important healthcare groups and lobbies.

So I want to know – are you doing all of this on paper?

I needed to vent. I needed to know I’m not alone in my frustrations as a nurse.

I’m so glad to know that our hospital isn’t the only one with so many forms. We know have a form to document whether a patient needs a foley catheter or not. I am expected to make spur of the moment decisions in crisis situations but not trusted to know whether or not a patient needs a catheter and at what point it should be removed. Go figure.

And with all of this paperwork to do, taking more and more time away from residents/patients; quality of care is suffering. HOW IN THE WORLD are Nurses and CNA’s supposed to provide care when they are filling out paperwork? How the funk are we supposed to do hands-on care when facilities won’t staff by acuity, and continue to staff by this, “warm-body,” theory? Guess who gets to change the dang toner cartridge when it runs out? Know what? Medical training to be a friggin’ secretary! (That to the Nurses among you.) I am married to a Nursing Supervisor; what does she do? She gets paid Nursing Supervisor wages to push the med cart 10 hours a day! They hired her to do all that paperwork y’all hate so much – then they call her on her DAY OFF to come in and pay her overtime to do the paperwork she was supposed to be doing when they had her pushing the darn med cart!

I left the world of Nursing Homes long ago in favor of in-home care because of the lack of staffing by acuity. As I watch the level of paperwork grow in the field of Nursing, I am glad I didn’t become a Nurse. Ay Carumba! The local hospital sent a patient with pressure sores on the BOTTOMS OF HIS FEET as an admission to my wife’s facility, despite a nice, fancy, high-tech bed in every single room in this hospital. Now what does THAT tell you? And where was the paperwork for this patient? Hmmmmm.

The demands being placed on Nurses in hospitals and Nursing Homes is WAY OUT OF CONTROL. Paperwork BE DAMNED> staffing by acuity is way, way past the point of being essential.

All the paperwork is only needed if the case goes to court, if it’s audited for outcomes – all things that don’t relate to direct patient care. You give report verbally to the next nurse. You chart for the future, for an administrator, case manager, state or jcaho worker, or lawyers.

I’m a fifth semester BSN student and I can so relate. In addition to all the flow sheets and various pieces of paper documentation throughout the day, we also still do all of our charting on paper (I’m doing my directed study in a small rural hospital). I swear I spend most of my time writing nursing notes and filling out flow sheets. This is not what I envisioned when I started nursing school.

I left the hospital for these reasons, swearing I’d never go back.

Eventually, I made my way to hospice. Sure, there’s paperwork, but the emphasis is on teaching, on psychosocial skills and nurturing your patients/families during the end-of-life.

I came home with my share of paperwork, but nothing at all like what was discussed in the first ICU post.

It was the area of nursing that was most focused on nurturing the patient, using the expertise of the whole health care team. Not nurturing or nurturing the CYA behavior. In hospice, I felt TRULY LIKE A NURSE.

And..if you have managed by a Holy Act of God to fill in every block..documented every minute detail..and have a living, stable patient to endorse to the next nurse..you are exhausted..mind like a fog..and what does the oncoming nurse have to say? Why is this on the desk..who left this chart out and why didn’t u do this??? We have enough to be accountable for and least of all a responsibility to our patients..when our so called “colleauges” come on shift and pitch an unholy fit about insignificant things..it just adds the icing to an already stress filled..nonstop 12 hours..We get no credit..no support..and walk on eggshells day after day.. the focus switches to CYA and burnout results.. results

You understand why correct? Legality and all? Look at what is coming out of the nursing schools today. Sorry folks but it is pretty darn scary.

I’m trying to feel for you, but my wife was treated in an ER against her will, and she managed to get out of bed, get dressed, walk to an exit, manhandle two security guards, and get forced back to her bed by four nurses where she had another seizure. Nothing in her record.

The reason its not in her chart is cause it took 4 nurses and 2 gaurds to manhandle the jackass taking time out of their Friggin overworked paperfilled day to strap her happy ass to the bed, and some mean lazy nurse decided to actually take care of emergent patients (including your headache wife) rather than take care of pieces of worthless paper. But hey! I could be wrong! But I doubt it.



So, what brought you to the hospital today?

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  • profileI am Gina. I have been a nurse for 15 years, first in med/surg, then CVICU, inpatient dialysis, CCU and now hospice. This blog is about my experiences as a nurse, and the experiences of others in the healthcare system - patients, nurses, doctors, paramedics. We all have stories!

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