The post-it reads ‘charting is a secondary job.’
This is very true.
Although the old saw that says if you didn’t chart it, you didn’t do it, you have nothing to chart without doing.
Too often people are enthralled with charting.
Charting must be done.
Charting must be done right now.
They are missing the forest. They are so focused on the trees that make up charting.
The charting should be the last step in your care for the patient.
The patient is in need of care. You provide it, then you chart it.
This is what charting as a nurse is; there is an action we have to document it.
The electronic health record has made it better and worse. The EHR boils down the entire encounter to check boxes and a narrative comment section that allows for observations that don’t fit in the check boxes. Because patients are individuals and are not all going to be check boxable.
Too often, the nurse wants to chart. Above all else. And the OR field or anesthesia is left wanting because the nurse is so bent on finishing the charting, regardless of attempts to sway them from the chart.
There is time enough to do both care for the patient and the field, and chart. But charting should not be a nurse’s primary concern.
The patient is.
Dispatches from the Evening Shift 