What's More Important: Charting Or Looking At Your Patient?

Overall, I think computer charting is nice. It offers a safe way of making sure you are giving the correct medicine, and correct dose, to the correct patient. In this way, it greatly reduces medicine errors. However, taking the time to chart, and chart accurately, takes away time that may be better served paying attention to your patient.

So, weighing the potential benefits against the potential risks is something that should be considered. But, in my humble opinion, other than the safety issue, the patient seems to take a back seat to charting.

Before computer charting, you had the option of charting in the room or charting after you were done. Some therapists preferred charting while doing a treatment. But, others deferred charting so that they could spend quality time with their patients. This is the option that I preferred.

As a kid, I was often in the hospital with asthma. There would be long periods of time when I had no visitors. Nurses were busy. And respiratory therapists only visited me every 4 hours to give me treatments. I got to know many respiratory therapists during the years my asthma remained poorly controlled. This would have been between 1980 and 1985.

My favorite therapists were those who gave me their undivided attention. Those therapists who looked at me, talked to me, and listened to me were my favorite therapists. On the contrary, I hated (for lack of a better word) those therapists whose heads were deep into their charting. They heeded me no attention. Their charting was more important than me, or so it seemed.

So, for the first 15 years of being an RT I never charted in the room. I promised myself, based on my personal experience, that my patient would always come first. This ended when computer charting came into place. Actually, it ended when we were forced to scan patients. Once this scanning mechanism was mandated, I was forced to chart in the room.

There are certainly advantages to scanning, as noted above. The security of knowing you have the right dose, medicine, and patient is handy. And, knowing your charting is done once you leave the room is nice.

But, this all comes at the expense of the patient. Some of our charting involves actually hunting through various options to find the options that you want to choose from. Sometimes this takes up to five and even ten minutes. So, by the time you are done, your treatment is done. And you spend very little time assessing and talking with your patient.

And I hate when this happens. Frankly, if I spend more than a minute in my chart I feel guilty. I would prefer to sit in a chair and banter with the patient, to get to know my patient. Some patients aren't very chatty. But, some patients love it when you watch TV with them, or banter with them, or simply chum with them. But this can't be done when your nose is in your computer. Thoughts?

The Chart Nazis

I think there is way too much emphasis on charting in healthcare, and not enough emphasis on the patient.  The longer I work in healthcare the more I realize this.

Just to give an example, my colleagues and I have maybe one or two experiences over the past 15 years where a patient, or patient family, complained about patient care.  Every one of those complaints was based on ignorance on the part of the patient or family member, and not on poor care by one of us RTs.

My colleagues and I get on average 2-3 notes a week alerting us to a charting error.  Once we master one area, the chart Nazis, as I like to call them, will find some other area of charting to focus on.  It's a never ending battle.

It's not just where I work either. I think even as you look at government regulations over healthcare, all, or most, of them tell a physician how to treat a patient with a given diagnosis.  There is no emphasis on the individual patient.

For example, all patients admitted with pneumonia must be sick enough to need one of the following in order to meet criteria for admission (translated means: criteria for reimbursement):

1. SpO2 of 92% or less upon admission, or an abg
2. Albuterol nebs or mdi every 6 hours
3. Antibiotic

There is no emphasis on the individual patient there.  There's this assumption that every patient is the same, or some kind of entity.  Individualism is lost in healthcare.  And this, my fellow RTs, is what is wrong with healthcare.  

Physicians are not encouraged to think outside the box.  For example:

• What if the pneumonia patient doesn't have bronchospasm?... too bad.
• What if the patient is too sick to go home but doesn't need oxygen or antibiotics... too bad. 

Personally, I think the current state of healthcare is unfortunate for the patient, because he's not going to get the care he really needs.  I think it's bad for the respiratory therapists and nurses, because the emphasis will not be on patient care, but whether those three things were done and charted correctly. Of course RT bosses will emphasize accurate charting, which is (ahem) where the dollars are.  

So when the chart Nazis come out in groves, now you know why.  

RT Cave rules for PRN treatments

So you have PRN (as needed) treatments ordered on a patient. How much time and attention do you give this patient?

Funny thing is, there are many RTs who work don't even bother checking these patients. They wait for the patient or nurse to call. I suppose, in a way, if you absolutely know the treatment is not indicated, this is fine.

However, there is some liability in that. If you have a PRN treatment, you must at least LOOK at the patient and chart.

Besides, sometimes a doctor respects the RT department so much that they order for PRN treatments even on patients with otherwise healthy lungs just so the RT can continue to assess the patient while the doctor is out of the house. Besides, who does better lung assessments than your humble RTs.

Likewise, some patients ordered on PRN nebs actually could benefit from treatments. Thus, given the argument I give here, those patients ordered on PRN nebs should be given the same respect as treatments ordered at a specified frequency. Or, in other words, a prn neb is that doctor's version of an RT driven protocol.

Thus, you should at least LOOK at your patient. If he is sleeping, chart he was sleeping comfortably. If he's awake, listen to his lung sounds and chart what you find. If the patient is fine, chart as such.

At our hospital we have a policy that this is mandatory. We have to check on the patient with regularity (at least Q4), and we have to chart that we didn't give the treatment and why. Some RTs think this is dumb. I think it's logical. How do you treat PRNs at your hospital

Of course, in a court of law, it'll look better if you charted you assessed the patient, as opposed to wrote nothing for all the days you worked and that patient lied in that bed.

RT Cave Rule #43: However annoying it may be, you should assess treatments ordered prn, and chart treatment not given and why. At the very least you get that all important procedure count, and make your boss happy.

Reimbursement criteria going a bit overboard

I had to laugh as my co-worker today told me that he was approached by the lady in charge of double checking charts to make sure we are complying with quality management.

The basic purpose of her job is to make sure that charting is as such that we will be reimbursed for therapy. She also has to make sure that the patient meets criteria for payment.

"Hey Dale," she said, "What is it with all these Q4 breathing treatments being given 10 minutes late or 10 minutes early.

Dale told me he looked at her with a blank face. What was he to say? He told her that we are a busy department, and because this is a job with many interruptions, we have to have some leeway in doing our therapies.

"But," she said, "In order for our insurance to pay, Q4 treatments have to be done every four hours exactly."

Dale said, "At first I thought she was joking, then I realized she was being serious."

What is the medical world coming to. Not only are we incapable of deciding who really needs breathing treatments, we have to do them exactly when we are told.

However, that's not going to happen.