What is a nurses priority in a hospital? Giving great patient care right? Wrong. To me, these days, it feels like documentation is the most important part of my job. The emphasis now in the hospital is have you filled in all the blanks on the computer that you need to in order to be compliant with JCAHO, Medicare, etc. Have you documented location, quality, aggravating factors, level of pain? After giving pain meds did you revital and redo level of pain 30 minutes after? Did you do discharged/admission vital signs? Did you reconcile all meds and record last time the med was taken? Did you fill in all of the many blanks around conscious sedation? Did you do the proper trauma charting so that statistics can be gathered? Screen for MRSA, VRE, TB. Did you screen the patient for potential abuse, suicidal thoughts? And these are just a few.
I spend the majority of my time doing documentation these days, crossing t's, dotting i's, filling in the myriad of blanks that need to be filled in. My documentation is tracked and if I don't do it right, I am given a note. A naughty nurse note. If it happens again I am placed in the staff time out chair in the middle of the ER. A third time? 20 lashes with a tourniquet.
o if you wonder why the nurse doesn't come in your room that often it is because she is out there documenting all the things that are required.
No comments:
Post a Comment