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New triple charting requirements

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We are now required to chart all meds given IV, IM, SC, in addition to Mar, and nurse notes. I know it's a new policy, I don't like it, but I will adapt. It takes an enormous amount of time. One of my pts received lasix, solu medrol, two antibiotics and IV flds, all at the AM med pass. Each of those meds had to be hand written out on a form, in addition to signing off the MAR. Our charge nurse told us it was a new medicare requirement. We are usually behind times where I work, and the rest of you may already be doing this extra charting. Does this sound familiar?
Staff has been cut to save money, and now we have this time consuming new requirement that is stressing me out. Do any other nurses have these new forms?
I work on a Med/Surg floor and we chart our medication administrations on the MAR and if its a pain med also on the pain flow sheet. What you explained sounds like it would be very frustrating, good luck.

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NOPE, we have a computer MAK entry, once charted is good, unless you feel the need to additionally write PRN's... I suggest you search AACN's charting standards, as well as seek legal help. The reason is the more you double chart, the more likely to miss a chart and documentation, not a med, and it becomes an error. This just sets you up for failure in too many eyes of litigation. You're now hung out to dry...... my inservices have taught me to NEVER EVER double chart. Someone, well meaning but ill informed started this trend and you can stop this if you gather the necessary info to refute it....It will be easy to find, and your new policy is dangerous.

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No, it is not a new Medicare requirement or everyone would have heard of it. The only place we double chart is the narcs. It's a waste of time for anything else. Some places have gone to all computerization, including a computerized MAR.

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I'm with the last poster. Narcs are important to chart in nursing notes because you need your assessment before giving and after. But regular meds? Unless something out of the ordinary happened, charting in all those places is - in my opinion - ridiculous, a total waste of time.

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We sign out narcs in narc book in addition to signing out on the MAR but that is the only double charting we do. I will usually put something in my notes about "scheduled medications given at this time" or "gave xanax 0.25mg for c/o anxiety" but that's about the extent of it.

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New one on me too. We are in the process of going to computer charting, so for now we have to chart both paper & computer. Hopefully soon we will drop the paper charts & life will be easier. I agree that this is a set up for missing something that will come back to hit you, the company will not support you nor will they take any lasting damage as they will quite willingly toss you out as a protection for themselves. I'd ask around in other area facilities to see if they have this policy too.

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My home health job requires us to double chart medication administration in narrative notes as well as on the MAR. I find that to be unnecessary and a waste of time. I also question the liability when one forgets to chart in both places. Ironically enough, a previous home health agency DOPCS told the nurses NOT to double chart in the narrative notes. Somebody with some sense.

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i work in ltc and i can tell you, we already document too much!! if you go to centers for medicare medicaid services and search around, there are no refrences to 'documentation requirements" if you go to medicare.gov, and key it in, there is no result that is apparant either. the only thing that is required and flags out for audits is..... psychotropic prn and standard med use. for a psychotropic, we need to sign mar, and write a note on what was tried before medication, and its effectiveness, then the effect of the med after x time is passed. this is still only 2x! for standing psychotropics, its a monthly note on how the med is acomplishing the care plan objectives. (or not acomplishing them) i can find no back up for your facilities new policy on the extra documentation. i would be thoroughly interested to see it though.perhaps you can help me then... ask your instructor or coordinator of this new policy if you can have the resource material ( web link or printed) because some other "nurse friends" heard you mention it and are interested in applying it to their practice. then you can come back here and let us know where it came from, or where to find the information ourselves, for verification! apparanly you guys know something i dont!of course my desired outcome is that upon re-reading the information, your coordinator realizes she made a mistake, and therein, i do not have to persue this in my own facility!either way, win win!!

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The charting is what makes the job hard. It is not the patients. Too much time charting and not enough of hands on patient care.

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Quote from clemmm78I'm with the last poster. Narcs are important to chart in nursing notes because you need your assessment before giving and after. But regular meds? Unless something out of the ordinary happened, charting in all those places is - in my opinion - ridiculous, a total waste of time.

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[font="lucida sans unicode"]we use the electronic emar system. that is a one time process. thank heavens. you scan the pts wrist band, the medications, and then thats it. the only other time you chart medications is perhaps a one time order or stating the pt was medicated for pain.

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Quote from cheyfire[font="lucida sans unicode"]we use the electronic emar system. that is a one time process. thank heavens. you scan the pts wrist band, the medications, and then thats it. the only other time you chart medications is perhaps a one time order or stating the pt was medicated for pain.
Author: peter  3-06-2015, 16:36   Views: 904   
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