• Chance Reaves

Charting is like a Dinghy in the Atlantic...

I normally like to give you guys some solid tips and best practices, but I thought I would throw one in for more emotional support today.

First off, I am well aware of the challenges that we as nurses face when it comes to nursing documentation. We are scared shitless in many instances.

nurse crying

We fear retribution from coworkers and doctors who don't agree with our charting...

Being written-up by managers for not charting "the right thing"...

Having complaints from patients because we charted "patient refused"...

Being sued by family of patients we lost...

And most importantly we are terrified that we will lose the one thing we worked so hard to obtain - our license.

Trust me, I know just as well as you do that getting my nursing license was a battle that I never want to give up. I'm constantly on high alert when it comes to CEUs and renewing my license.

But the reason I bring this all up is because today in a conversation there was discussion that larger organizations like The Joint Commission and CMS are beginning to ease restrictions on some aspects of regulations and compliance, which can directly and indirectly affect charting. They say that documenting x, y, or z may have been overkill in the past. So, they're seeking to change those restrictions for the sake of nurse burnout and to attempt to improve standard of care (granted, there are lots of nuances, I can't go into the details).

As frustrating as it seems as though they talk out of the both sides of their mouths at times, I get it though. They want to protect the interest of the general public and community, and their intentions aren't to make our jobs more difficult. But this is where I feel like we can sometimes feel like being in a dinghy in the Atlantic ocean...

tiny boat in big ocean

We have this vast open space (what we interpret to be correct "charting), complicated by sharks, stormy weather, and the dangerous nature of the elements (TJC, CMS, and other regulatory bodies). It feel like no matter what efforts we make, we can't get to shore. We have to weather the storm, and deal with whatever obstacles are thrown our way. Many times it feels like a never-ending cycle of back and forth.

Because of this, I want you to remember two things.

First, I have long had the stance (which will continue, until I'm proven otherwise) that charting is an art form. I often reference Bob Ross (see this blog), and how you need to use the tools at your disposal (including your critical thinking, intelligence, and previous knowledge) to paint a holistic picture of your patient.

And just like Bob, he never painted the exact same way. He made adjustments in his colors and technique to enhance the painting by bending his efforts to produce a beautiful picture.

At the end of the day, there are really only a couple of big rules that you need to follow - maintain patient privacy and security, adhere to the standard of care mandated by your hospital and government, and provide concise, demonstrable communication of your patient to your team.

Secondly, give yourself some grace if you are new at this. Understand that not only is charting a complex practice, but the software that is required to do everything like communication, billing, patient records, medications, labs, etc, etc, etc is wildly complex, but it takes time to master. In many cases, it takes up to 6 months to feel comfortable with the software, let alone proficient in it. Grace doesn't mean clocking out early, but it's allowing you to feel uneasy if you need to go triple or quadruple check your restraints or medication record.

And that's ok.

It comes with time. I honestly never really felt comfortable charting until I was about a year in. I remember that one day I had time to go in and have a lengthy conversation with my patient and their family. I kept feeling this uneasiness - like I had this nagging feeling that I had charted so fast that I missed something. But everything was done. And it made still made me uneasy. Only after more time passed was it that I got comfortable.

Always remember that nursing, in whatever path you choose, is a lifelong journey of learning. Always be uneasy...that's part of it. We literally have the lives of our patients in our hands, and we must provide care to our patients, and we must take care of that responsibility.

I'll leave you with this quote from Bob Ross -

“Talent is a pursued interest. Anything that you're willing to practice, you can do.”

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