Caring for the Chart or the Patient?


SAUSALITO, CA (ASRN.ORG) -- 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.



Copyright 2012- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved


Articles in this issue:


  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

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