Ponder this question, DON couldnt answer..

[Christof60]

A few months ago, I was getting my 90 day evaluation (after 2 travel contracts, then hired on FT)... I recieved a great review, then was asked to voice (vent) my thoughts, concerns...
Working here in Florida, there is this thing called "Season" where half of the north comes to Florida, many in ill health. It is the craziest work environment I have ever seen... Anyway, this review came at the end of "Season".. While quickly pondering what to say, and how to say it, this thought came to me in a flash.. With all the stress nurses have to deal with simply doing their job, then adding all this "JCAHO this" and "EMTALA that", and "Patients must be seen within 5 min of arrival, even if their tooth has hurt them for two weeks", this is the one basic "catch-all" question I had for her.. Here goes..

"If all parties involved, legal, state, federal, JHACO, EMTALA, etc., can be satisfied with an MD (who really has all the liability) using one form for each patient, why do we have a minimum of 30 min of computer work/paperwork per patient, even a well-child exam??
She really couldnt answer beyond the typical administrative answer I have heard for 14 yrs.. "We are constantly trying to minimize and streamline the paperwork and charting process"...

So, for all you nurses out there that buy the "It is JHACO mandated" and "It is a federal requirement", answer that question for me please. Why are doctors allowed to simply fill out one quick-fill form and we arent?
I could double my workload, AND improve my patient care, if it were as simple for us as it is for MD's..
In my mind, I think it is more a matter of an over-abundance of higher educated medical professionals that if not for making, imposing, reviewing, and enforcing "regulations", they would be out of work... Nothing else makes sense, because I refuse to believe that regulating bodies place more responsibility on nurses than they do MD's.... And I also believe it is because MD's do the minimum, and if held to a higher expectation, a certain finger of theirs gets held higher...

Now, what say you all??

[SoldierNurse]

Let me do some pondering before I do anymore posting on why I might figure it is that we nurses [even military] must kill the proverbial trees during the course of patient care.

LOL, such deep questions are making my shoulder hurt.

[ruby43]

(smile)...yes, it seems in the wonderful world of technology, we still seem to have more paperwork than ever. The paper shredder is always too full to work, the recycling bin is over loaded...and we still carry around a ton of papers. JCAHO and all those governing bodies seem to think that we have to "show" on some sort of flow sheet, check off sheet, and other signed documents that we are actually doing what we are. And now HIPPA comes in, and we can't even have all those papers we were told to have, out in the open to public view!! So now we have to keep it hidden, or turned face down, or covered up! When will it end? I feel for ya'! I can definitely relate, I am forever being told that I don't document well enough in as many places I should...but I guarantee, my patients are well taken care of. Oh well...hang in there. Ruby 43.

[BeachyCEN]

]All I can think of is, if it is not documented, it's not done...learned that in nursing school [/COLOR]

[cassioo]

Our docs don't really fill out anything they dictate so all they right is seen H&P see note then talk on the phone and lots of the info they have for their dictation are those notes that we record

We fill out a "self eval" before our yearly eval and my thing I don't like about my job every year is the paperwork. The thing I like stays the same too...my goal well really nothing to do with nursing (or nursing at this hospital) and they don't want my yearly personal goal of losing weight which is never met.

[Christof60]

Originally Posted by BeachyCEN

]All I can think of is, if it is not documented, it's not done...learned that in nursing school [/COLOR]

And A LOT of what we learned in nursing school was bunk.. Why do you even need to do complete VS on someone with a fish hook stuck in their finger and 18 yrs old with no medical hx??
Doctors all the time love to say "we may open a can of worms" when you suggest certain tests, other times they are doing LP's on 4 mo old's with a 99 deg rectal temp... No rhyme or reason in this profession anymore... I remeber the "good old" paper (pre-JHACO) days when everything you needed to document was.. i.e., the damn reason the pt was there, what you did to resolve the problem, and the outcome....
I long for those days...

[stellar]

How's this for "efficient": My 5 year old daughter dropped a glass on her foot and had a laceration. I brought her to the ER, was at her side the whole time. They checked her foot, stitched it up, and off we go. Totally appropriate care for the injury. Later, I get her medical record and it has a FULL physical assessment documented, heart sounds, lymph nodes, lung sounds, etc. None of this was done. I call the hospital administration and say, "listen, this is a legal document. If tomorrow something happened to my daughter, this record would be the legal truth of her condition, and care would be dictated accordingly, and this is a complete fabrication." Come to find out, the transcription service had a mechanism in which the doctor simply said "normal" for that system, and that generated a dictated note of a full "textbook normal" assessment for that system (and they all knew it.) They promised to advise the doctors to only use it if they really did the assessment...Scary!

[Reneec]

I'll never forget the 80 year old man who came into our office and complained about his incorrect bill. We had charged him for a pelvic exam! The customer is always right, right?

[Beaches]

Ok, started at a new hospital with McKesson system and did my first direct admit (with no supervision) - it was unreal... I now know what my patient's second cousin removed, that was married to her husband's niece, medical history. ABSURD! Concise medical history is the only thing I am looking for. A two hour intake history is way too much nursing time to spend to click on all that and really not be relevant to my patient or present concerns. Cut out the check list BS and just let me chart without having to search for the correct category to chart it in.
Talk about a dinosaur, we have reverted rather than progressed.

[orionseal]

I only have this as a reply.

I SAVED 3 LIVES TODAY, BUT I KILLED THIRTY TREES IN THE PROCESS.

I do agree with you though, we have to document everything we do even a simple thing like a fingerstick just to rule out that problem or another,blah, blah, blahhhh and what about all the inocent pens we slaughter for the sake of regulations?

Dr's only have to pick up a dicta-phone and talk gibberish for a moment or two then move on to the next patient.

When do we get our dicta-phones?