There's kind of a charting rule in nursing. Redundant documentation is a waste of time. There's absolutely no good reason to duplicate information in your documentation, especially when it's written over and over again. Let me explain: I am a home health nurse. We are essentially "allotted" a certain amount of time to perform an assessment on a patient, provide the indicated care and treatments, and document everything in writing. Our assessment and care for a patient admitted to home health is documented on some 15+, printed back and front, stapled together pages. Then add to that another 8+ pages of assorted documents, and add that up... A LOT OF PAPER, and a lot of writing.
OK, so I am certainly not complaining about required documentation. That's necessary for obvious reasons. Nurses are used to it - it's just part of the job we come to accept. What I AM complaining about however, is all the DUPLICATE documentation. I am finding it harder and harder to tolerate the waste of time (and it can add up to a lot of time over the course of a day... a week...) that writing things like a medical record number, or patient's name, or their pharmacy... over and over and over again... well, you probably get the point.
OK so after the nurses document this "book" on every patient (extensive documentation is done every two months, yes, every TWO months) and add to that all the notes from "regular" visits... OK, so I got off track here and created a run-on sentence, but it's my blog and I am on a roll.... I digress... so after we write this book, our office staff takes the time to input ALL this data into a computer. Hmmmm, does this make ONE BIT OF SENSE to anyone? I don't even own the company, and I get paid on an hourly basis, but I still care that this many trees are being wasted through the shredder at my work each day. And I care that my time is being wasted this way too!
Take the money you save on paper and buy a cheap laptop for all the nurses and therapists. Invest in some smart (NO redundant charting allowed) software. Let me chart on the computer when I am with the patient. I can place my laptop on a docking station at the office where the data is uploaded to the master mega computer... then the office gals can do whatever they need to do with the information from there, and NONE of us ever have to do this crazy duplicate, time-wasting, manual documentation ever again. And guess what? We'll have more time to spend taking care of our patients, which is what it's all about anyway.
I've had a difficult few days at work, and this charting is just the icing on the freaking cake for me. My attitude about this is ugly and I am sorry it's showing right now. I love, love, love patient care - as much as any nurse on the planet - but wasting my time with senseless, antiquated methods of documentation really pushes my buttons. And since this is my blog and no one reads it I feel very safe venting here! LOL!