Nursing Notes

February 7, 2011

Caring for the Chart or the Patient?

Filed under: Nursing — Shirley @ 12:59 pm
Tags: , , , , ,

Here is another wonderful article by Theresa Brown in the NY Times.  I really recommend any article she writes, as I believe she is uniquely able to articulate the thoughts and feelings of the staff nurse so that the non-nursing population can see the problem and can feel the stress that nurses work with.

This article points out the ridiculous need to chart “everything” for all the differing agencies that oversee healthcare today.  Charting now seems to take up the majority of each nurse’s shift.  Patient care seems to have been neglected, or worse, lost to this pile of needless paperwork.

I like her idea of a camera that follows the nurse around so she can concentrate on what she does best–patient care.  Maybe there is a nugget of a solution in this idea.  We need someone, somewhere to address this issue so that we nurses can get back to our patients and away from the charts.

Please do visit this site and read more articles by this nurse.  You will not be wasting your time and you will definitely get a feel for nursing today.


February 2, 2011, 2:17 pmTheresa Brown

<!– — Updated: 4:35 pm –>


At a recent medical conference in Miami, I sat spellbound as Dr. Stephen Ferrara, a commander in the Navy, delivered a keynote address describing his work in a mobile hospital in Afghanistan.

Dr. Ferrara is an interventional radiologist, a doctor who uses medical images — CT scans, ultrasounds and the like — to treat abscesses, biopsy hard-to-reach masses, check blood flow and cauterize bleeds. He first went to Afghanistan as a medic, then made a place for himself in the operating room, where he placed micro-stents to restore blood flow to damaged tissue, checked perfusion to save legs that would otherwise be amputated and embolized wounds to stop blast victims from bleeding to death.

It’s undeniably grim work, but done with a driving sense of urgency and very few administrative distractions. It may sound odd and naïve to say this, but watching the presentation, with its slides of horrific wounds, I was surprised to find myself feeling envy. He and his team members were free to attend to the area of greatest need: the patient. They were focused on care to a degree that I am rarely able to experience in my own work in the hospital.

Hospital nurses are required to do paperwork, or “chart,” throughout each shift. We do a full assessment of each patient at the start of a shift, and chart that on electronic flow sheets packed with a dizzying array of drop-down menus. If we have time, we document discussions with doctors, when a patient left the floor and when she came back and how we responded to an abnormal vital sign.

The mantra we all learn in nursing school is, “If it isn’t charted, it isn’t done,” an impossible rule to satisfy. Since what could be charted is infinite, I begin each shift feeling that I have already failed in my documentation.

In addition to charting the events of the day, there are required pieces of documentation that address the concern of one health care agency or another. In 2005, the Joint Commission for the Accreditation of Healthcare Organizations put “falls” on their national patient safety list, so our charting now has to exactingly detail our commitment to fall prevention. The Centers for Medicare and Medicaid Services will not reimburse the cost of treating bedsores that develop during a hospital stay, so a new drop-down menu charts whether a patient is at risk and whether they have pressure ulcers already.

The requirements come fast and furious and often have a flavor-of-the-month feeling. One large insurance company was concerned about a specific type of hospital-acquired infection, so for a while every patient had to be tested for that drug-resistant bacteria. We’re now done testing for that infection but get scolded for not consistently testing for another one.

Certain kinds of lab results get called in to the floor nurse, and we’re supposed to report them to the nurse practitioner or physician who is following the patient. Then we have to chart when the lab called us and when we delivered the message.

All medications must, of course, be charted. Intravenous drugs include a huge drop-down menu for noting the location of each patient’s IV line, a step we need to take every time we give the medication, even though the access location does not change that often. And every time we give a pain medication, we have to scroll through multiple drop-down menus to chart the level and severity of the patient’s pain, where it hurts, how sedated they are and how they describe the feeling of pain.

One accrediting agency is focused on education, so there’s also a separate menu for noting that a nurse provided patient education. Another menu charts more long-term care concerns, an important issue for the board of health.

I have joked that the hospital should install video cameras to record everything that nurses do. Having a permanent record of my actions would mean that all the time I spend charting could be time spent on patients instead.

Because that’s my real concern: the effect on patients of incessant record-keeping. Each of these individual initiatives has merit and is worthwhile, but together they become a mishmash of confusing and oppressive paperwork.

I had a patient recently whose cancer had recurred and spread. I had bought a button in the hospital gift shop that reads “Cancer Sucks” and was wearing it that day at work. She really liked it, but I knew it wouldn’t be easy for her to get to the gift shop to buy one. So later that evening I visited her room and gave her mine.

“You earned this pin,” I told her. Then I saw her eyes light up with recognition. Someone — her nurse — understood what she was going through.

The care we give our cancer patients is obviously much different from what we do for soldiers who’ve had their legs blown off by an I.E.D., but the threat to life and limb is no less real. I have no drop-down menu for charting “Empathized with patient over fear of metastatic disease and death.” And yet, that’s exactly what the patient needed.

“If it isn’t charted, it isn’t done,” we hear. But as the paperwork demands proliferate, my worry is that if it can’t be charted, it won’t be done.

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  1. […] Caring for the Chart or the Patient? « Nursing Notes […]

    Pingback by Charting AUD/NZD: Turn Achieved « ádasd — February 7, 2011 @ 5:00 pm | Reply

  2. […] Caring for the Chart or the Patient? ( Blog this! Bookmark on Delicious Digg this post Recommend on Facebook share via Reddit Share with Stumblers Tumblr it Tweet about it Subscribe to the comments on this post This entry was posted in Nurse and tagged assessment, caring, charting, documentation, EMR, Health, Health care, healthcare, Medical record, medical records, New York Times, nurse, nurses, nursing, nursing issues, patient, patient care, red on the screen, registered nurse, rn. Bookmark the permalink. ← Nurses and the Bullying Experience: Lateral Violence blog comments powered by Disqus /* […]

    Pingback by Getting the Red off the Screen: Charting or Patient Care | The Nerdy Nurse — February 21, 2011 @ 7:02 pm | Reply

  3. This is a really interesting article, I find it sad how patients are not central to care these days.. Thank you for sharing, I really enjoy your blog!

    Comment by Student Pharmacist — March 9, 2011 @ 9:29 pm | Reply

  4. I really, really enjoyed this article. I do not like the camera idea[too much like big brother watching], but have felt exactly like this nurse for years. I have even thought of getting a job in another country so I could actually ‘nurse’. Where have all the nurses gone? They are stuck in the charts!

    Comment by Donna L Hames — April 13, 2011 @ 3:18 pm | Reply

    • Donna, I’m glad you liked the article. I also feel this nurse’s frustration. In my career as a nurse, I have watched my time be eaten up slowly and steadily by regulations and requirements of billing agencies and federal agencies. In the mean time, my “nursing time” has become smaller and smaller until now, the only contact I have with my psychiatric patients is when I am passing medications. I hate it. No wonder there is a nursing shortage.

      Thanks for posting. Please come back again and let me know your thoughts.


      Comment by Shirley — April 13, 2011 @ 7:13 pm | Reply

  5. Wow…What a fabulous article it was…I have never read a great article on Nursing…really the author deserves my hats off…Keep it up…I want to see more in future..

    Comment by LPN programs online — May 25, 2011 @ 9:31 am | Reply

  6. I bookmarked this site for the useful information.

    Comment by Jacob — June 13, 2011 @ 7:38 pm | Reply

  7. A very nice article related to nursing.Hospital nurses are the backbone of the hospital.But now a days folks interest related to nursing is decreasing.What is the reason behind this?Either there is no facility for nurse in hospital.

    Comment by online LPN — June 13, 2011 @ 11:30 pm | Reply

  8. Ya, nursing work has stress. But, it is a respectful job for women. I like this article related to nursing problem. I love and respect this profession. I suggest to all the folks respect the nurse because they are the backbone of hospital and enter into this field for helping the human beings.

    Comment by online LPN program — July 22, 2011 @ 1:04 am | Reply

  9. I would say that nursing is a respectful job for ANYONE. I worked as a nurse for 30 years. As a nursing student in the 60s, I had an instructor that did her best to get me out of the program because she felt men didn’t belong in nursing. I was the first male in the program and the only one in my class. That taught me so much about people. It is a lesson that I have carried with me for many years. We must respect everybody, nurse, patient, physician, clerk and other team members. Learning from each other is paramount. Today, I tell students my story and hope they learn the lesson of respect. The other lesson is that they must learn to work smarter, not harder. Hats off to all my colleagues!

    Comment by Michael Corey — August 10, 2011 @ 10:46 am | Reply

  10. […] Caring for the Chart or the Patient? ( […]

    Pingback by Getting the Red off the Screen: Charting or Patient Care — July 23, 2017 @ 11:51 pm | Reply

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