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Nursing2015

April 2005, Volume 35 Number 4 , p 14 - 14

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Abstract

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    At times in this busy medical/surgical unit, I seem to have more paperwork than patients. I have so many forms to fill out that I rarely complete all of the information on every form on every patient on every shift. Here's an example: To give just one p.r.n. I.V. medication for pain, I have to document it on the medication administration record, then chart it again on a separate I.V. record form in the patient's chart. Because the medication was p.r.n., I must also document it on a third form that documents p.r.n. medications. Then I must provide the same information again on a form that the charge nurse uses to give report at shift change. Finally, I document everything all over again when I write my nurse's progress notes in the computerized record .

    I understand the need to thoroughly chart medication administration, but couldn't all these redundancies actually increase the chance of erroneous or inconsistent ...

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