Documentation Questiion - page 2
by JustBeachyNurse 3,595 Views | 10 Comments
I work 12hr shifts in pediatric home health on a case that I split with another nurse. Even from back when I was an EMT eons ago, a tech, research tech and now a nurse I was always taught that my notes should be "stand alone"... Read More
- 0May 15, '12 by BuckyBadgerRNQuote from JustBeachyNurseI do home health with a little one too. I personally like to document what I see, not what someone else sees. I think I write good notes (thorough, very descriptive--20 years in EMS will do that to you, LOL) and when I read back over other nurses notes, I see a couple of them using phrases that I do. I'm certain that they are their own observations, just "my" verbage.We do handwritten paper charting. I have a certain style of writing my narratives. She copies a lot of the specific phrases that I use which to me is not an issue if appropriate. (like "resting quietly, eyes closed, respirations equal and unlabored; side rails up and brakes in locked position). Sometimes you read a chart and get an idea of how to phrase something. But it just seems odd to me to not write out your OWN observations when charting an assessment and simply writing a reference to someone else's assessment (red mark on leg as noted in nursing notes from <other date that you didn't work>).
Just wanted to make sure I am documenting correctly by writing out my own observations each shift
I don't know if our way of documentation is "right", but I sure feel a whole lot better with the very complete way you and I seem to chart. JMO....