You are reading part 2 of my series, “Avoiding Hospice Burnout.” If this is your first time reading this series, please visit my first post by clicking HERE. This will help you get a quick overview and the foundation for this series.
Today, we will be discussing what is the single biggest thing that causes burnout in hospice. Many readers are coming here from the Hospice Nursing Support Group on Facebook. This series was motivated in large part by many posts from that group. There is not a day that goes by where this is lamented. Today, we will address this directly. Hold on to your nursing cap, this is gonna get real!
Chart at the bedside
Okay, I can hear the moaning from the back row. I considered saving this for the very last post. I’m worried about how many readers I will lose after just my second article in the series. For some inexplicable reason, this concept gets mountains of pushback. Why would someone want to intentionally wait till the end of the day to do all their charting? Do you hate yourself? Do you feel like you don’t deserve a personal life?
Maybe we can call it “field charting.” This seems to help it land a little softer to some people. This concept encourages charting to be done before showing up to your next visit. This means you chart in the driveway or around the corner. I still don’t like it, because it results in less time with your patient.
Let’s take a few minutes to debunk a few of the reasons I hear for not charting at the bedside.
- “It’s rude to open my computer in front of my patients.” In my six years in hospice, I have been asked to not open my computer less than 5 times. Computers are a part of medicine now. They have been for 25 years now. I saw a cardiologist a few weeks ago. He had his computer out the whole time. Join the new millennium. Everyone else has.
- “I don’t have the time to chart during the day.” This is the least believable of all the reasons. What takes you 10-20 minutes while you are with the patient will take you 30-45 minutes at home. Home can be a full-time job for many of us. Husbands, wives, kids, friends and responsibilities pull at us the second we walk into the house. Home is absolutely the worst place to do your documentation. Many nurses end up in bed and chart from 9pm-11pm every night. What a disservice to your patients! What a disservice to your family. What a disservice to yourself!
- “This system is way too hard to use.” In my hospice career I have used 5 different EMRs. I have been able to successfully chart at the bedside with every single one of them including HCHB. This can be done on any system.
You’re here for help, and I want to help you. Let’s start by just being honest. In fact, you don’t have to even be honest with me. You don’t have to tell me the truth. You can lie to me all day long. Will you stop lying to yourself?
I have been in leadership for the last 4 years. I have ridden with many nurses, and I have watched them work up close. I have come to a simple conclusion. Nurses don’t chart at the bedside because they just don’t want to chart. There, I said it.
This honesty is your first step in overcoming this hurtle in your hospice career. Say it with me right now, will you? Are you ready?
“I’m not charting at the bedside because I just don’t want to chart.”
Look, I get it. None of us went to nursing school for the charting. None of us love it. Well, the crazy compliance nurses love it, but they are a different breed. Charting is a part of what we do, and hating it hasn’t got you very far, so it’s time to do something different.
Okay, now that we have that taken care of, let’s start anew. Remember when we talked about intentionality? This is where the work gets real. You have to become determined to be successful at this. You have to decide right now that you will make this a priority. If you want to avoid burnout, you have to start right here with charting at the bedside. This is step one.
Over the next few articles, I will address several ways to become successful at charting at the bedside. For now, I will leave you with one strategy that helps to address the first fear from above.
Many nurses when starting to chart at the bedside make the mistake of opening their computer the minute they walk into the home. They think to themselves, “I better get going on this right now, or I’ll never get good at charting with my patient.”
Don’t do this! Take the first 10-15 minutes of the visit to sit with your patient and their caregiver. Give them that undivided attention that we know they crave. It’s one of the reasons we got into this work. You will complete your assessment during this time. During conversation you will notice if they have a chronic cough or how short of air they get when talking. At some point, the conversation will become more technical. Use this moment as a reason to dig out your device and get started. If you have been using your system for any amount of time, you should be able to document a comprehensive assessment in 20 minutes and a focused assessment in 10 minutes.
As promised in my first article, here is how to identify if your organization is getting in the way. If your caseload is so large you have more than 6 visits in a day, your organization is in the way. If you have been trained to click and type in every single box for every assessment, your organization is in the way. Your comprehensive assessment should take 20 minutes and your focused assessment should take 10 minutes. Visits should last 40-50 minutes on average.
Feel free to comment and engage in conversation below in the comments. This is a robust concept, and it can’t be resolved with a single post. It takes time, effort and intentionality!
Visit The Hospice Nursing Community for more assistance in avoiding hospice burnout.
Love this. It is so much easier to get the correct times in the computer and remember everything you need to remember when you get it down as it happens. Also if you have your computer open and put anything at all in it, it takes more time to close it, leave the house, go around the corner and sign back in tot the internet, pull the chart up, login to various security walls etc. Great idea you should have all the info you need by the time the computer opens and you out in what you just spent 20 mins collecting.
You taught me right! I owe you so much, Mike!
Like to do this but live in a rural county with poor and nonexistent cell and internet service. We need an offline option to chart in the home and transfer when there us service. Even cells phone don’t have service in many areas, you may be able to text, but not talk.
That would drive me crazy, Diane. In your situation, I would probably end my day at the office and do my charting. I would absolutely refuse to chart 5-6 visits a day at the office or home. It’s not even what Medicare wants.
I am also in a rural area with sketchy cell service. I chart when I get back to the office. Never at home.
Great job maintaining that boundary!
The reason why this doesn’t work for me is the families tend to talk while I’m trying to chart and I need time to do it without all that distraction. So I do it right after the visit.
Hey, thanks for reading my article.
It can be really hard to chart with family jabbering in your ear. I do have some nurse who Field Chart like you do. It’s the folks who wait till they get home who worry me the most.
I have to do the same thing,.
I have been a Hospice RN for 29 years and the best habit I had when I was in the field was charting during my visit! I never had a patient or family ask me not to chart. If you utilize your listening skills you will pick up on those times where the charting needs to be done after because your patient needs all of your attention. Because I always did my charting during my visit, my patients just knew it was part of what I did. With practice you can become an expert at it! The only things I had left at the end of the day to chart were any phone calls or MD orders obtained throughout my day.
You are correct. If you start bedside charting from the very first visit, nobody expects anything else. Thank you for checking in!
I’m a patient, not a nurse. And not in Hospice care, thank God. But at age 76 I have been to the doctor a number of times and expect to visit a number of more times before I pass. They take notes at their computer while they’re evaluating my problems, and I love it. All of those notes are then available for the next doctor, as I don’t get the same one every time. But because those notes are there the next person can take up where the previous person left off. It is not an intrusion; it’s part of the process. So, for those Hospice people who don’t want to chart in front of their clients, I do think people understand why this is done.
Thank you, Joseph, for sharing with us your real-world experience!
I never had a problem charting on a computer in front of a family. My cell phone, however that was a different matter even thought I educated some of my elders on it. To keep the peace charting was after the visit, in the car nearby, or at the office.
Thank you for adding your experience to the conversation!
Hello, thank thank you for the Fresca perspective. I’ve been an LVN for 7 years, I’m new to hospice (I’m about one month in.) My organization just switched to HCHB. I found your articles in my research, I’m trying to gain a different perspective from what I’ve been taught by most of the higher seniority nurses so far, which is “Don’t chart during the visit it’s just rude.” Or similar laments. Yesterday I worked 11-8 and ended up charting from 10 PM to midnight and that was the final straw for me. Not only was I tired but I couldn’t remember everything, thank goodness for my notes. I had a feeling there has to be a better way and I found these articles. Thank you for sharing your experience and encouragement!
Sarah, I’m really glad you found this material. It’s not rude to chart in front of your patients. You deserve a personal life, and hospice patients deserve a very accurate medical record. There is no good reason for you to wait till you get home to do all your charting.
A question about hchb.. the question of did you assess eligibility, we are told to always answer yes.. and then it quizzes you about pps, mac, ect. I despise redundancy so sometimes I will mark no on pps or mac, (when in fact I have just charted it in the vitals and tests and measures).. think will ever haunt me? my thought is if i put in a different number by mistake that is worse than putting it in once correctly.
Well, I have worked with HCHB for probably about 2 total years of my hospice experience.
HCHB is popular (mostly) because of the back office. It has A LOT built into the back office to avoid billing mistakes. It is very efficient at this.
HCHB is not really very nurse friendly. There is A LOT of redundancy in that system. My motto has always been, “Just make it happy and write a really solid narrative note.”
In my experience so far, and I welcome correction on this, most surveyors skip all the check boxes and review the narrative note.
Getting caught up in all the check boxes and text boxes is a really big barrier when it comes to getting our charting done timely. You have to click the check boxes where appropriate, but don’t let HCHB force you down a lot of dead ends. It is really good at that. Focus on the narrative, and you should be just fine.
Hi, James!
I have been a hospice nurse for 12 years in different settings (IPU, case management, and currently QA and Informatics). I have used Cerner, Thornberry, Netsmart/MyUnity, and am now using Suncoast EMR. I agree that surveyors often look at the narratives, but if they miss something in a narrative we also point them to the fields within the assessment forms.
In Suncoast, I think filling out the assessment forms is more important than the narrative because Suncoast has the history button (“little clocks”) next to every question in every assessment and also in the Priority Clinical Details and Clinical Details in the Snapshot (the initial page of the pt chart). These history button make tracking items such as pain, etc. very efficient. If the pt pain is an 8 on a visit, you fill in that field and you can also look at the history to see it was a 10 at the last visit, a 5 before that, and so on and so forth. It tracks every time each field is ever filled in. It is fantastic for tracking weights and MACS too–it’s what our physician’s use to complete their recertification CTI’s. If information is put in narratives, there is no easy way to mine that data without opening narrative after narrative after narrative…. Suncoast is a very “clicky” system with lots of checkboxes and fields to fill in, but there is great value in filling out the forms as they were inteneded. It also makes it easy to run reports on specific data elements.
Just my 2 cents. Other EMRs I have used haven’t had the history button like Suncoast, so the data fields were not as useful. As far as Suncoast goes, they’re extremely helpful. Really enjoy your content!
Hi Alicia! Thanks for reading and sharing your thoughts.
Suncoast was my first EMR back in the day. I remember how helpful the history buttons were. I wish more EMRs used them. Especially when trying to complete a recertification visit and narrative!
HCHB, is it really possible to chart in 10 minutes? The program will not let me save the visit if it is less than 15mins. I am also 6 months in as a hospice case manager. I am struggling with a case load of 20 due to most of my patients are home residents and the drive time. I have mapped out my weeks every week and it always changes. When is there time to reorder meds, set up pts medi planner, order supplies, document scribes for IDG meetings that last 4 hours one day a week, attend new hospice nurse meetings once a week and update families while returning patients phone calls? I ended up getting pulled over by the police because I wasn’t paying attention the speed limit changed because I was on the phone with a family member and trying to get to my next appointment. Not all days are bad but at least 2-3 a week are. I see my coworkers have a caseload of 20 but they are all in 2 facilities with in 5 mins apart. My drive time between visits are 15-40 mins apart. I love these tips, but I don’t see how this ratio can work.