Documentation Questiion

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    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" documentation. If another staffer makes a footnote on a chart or document, I should not "reuse" their note as I'm not the one who initialed and dated the footnote but instead I should make my own footnote in my own words. If another staffer documents a finding such as a rash or wound I might refer to it as "3x4cm area of erythema noted on anterior right thigh above knee, originally noted on 1/1/01 by previous shift...". But I should NOT write "erythema in right thigh as described in 1/1/01 nursing note, especially since hopefully the site doesn't look exactly the same as it did a day or two previous. Plus I am not the one who made the previous observation.

    It was a major issue in research if you used someone else's footnote. (I did some work with QA/QC and I know the rules of FDA clinical research are similar to nursing standards but in some areas research is more strict.)

    The reason I ask is the other nurse constantly "reuses" my footnotes even if they are not exactly relevant to her shift (such as if I reference a particular day's scheduling issues (extra appointments) that were a one time issue). The patient had some minor skin breakdown and a petechia like rash. Rather than document her own findings (and the area had to be improving since it was nearly resolved by the third day when I returned) she just referenced "rash on leg as noted in notes from 1/1/01".

    I measure the area and fully describe my findings (share, color, any open skin, drainage) plus any actions or interventions (called doc, called supervising RN, etc)

    So am I making myself more work by describing what I find and only referencing the original discovery (area of erythema as originally noted on 1/1/01)? Or am I documenting properly? I am not too worried about the other nurse unless she tries to change my documentation again (she decided to change my footnote without initialing and dating in the chart, the nurse case manager took care of that issue), as that is an issue for the office to discover and correct. I just want to make sure what I am doing is correct.
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  3. 10 Comments so far...

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    I don't work in home health, but I have not seen a documentation system that allowed or encouraged references to another clinician's assessment. Various electronic systems have the ability to copy/paste ... but when you use that function you are using it to represent that wording as your own observation, not simply stating that what you observe is the same as what someone else observed.

    As you note - there is likely to be some change in the appearance from day to day anyway ...

    I'm not sure how big a deal this is ... but it just doesn't sound like something I would do.
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    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
  6. 0
    I agree ... I've picked up certain verbage that I like from others nurses with whom I've worked. I was using the copy/paste example as an illustration of that.

    And as I said, I agree, I would not reference another clinician's observations as my own.
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    i once worked directly with a hospital administrator who audited my work (lucky me!) --- it was one of those random things for quality control.

    since day one of nursing school, i've always been told to always be precise with my documentation no matter how busy i get in order to protect my license. so when i was audited, the administrator was surprised that someone so young was doing way better than the "experienced" nurses; mind you, i've always debated with myself if i was doing way too much since my senior nurses would tell me that i was too "precise."

    after being audited --- i was scared out of my mind --- and the administrator being happy with my work, i felt more confident that i was doing the right thing to represent my company if jcaho (the joint commission) happened to stumble across my work.

    the administrator then had me make a booklet to help refresh my colleagues on how to document properly. i was also given expressed directions that if anyone tried to give me lip to contact the administrator's direct line so s/he can come down and teach the unit personally. *ouch

    justbeachynurse
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    i don't think you're making yourself work hard. you're doing the right thing. as for the other nurse, i think she just needs a friendly re-education; just let her know that in order to protect her license she ought to use her own findings (if there is definitely a change in the patient's status). also, it would help a lot to see if there were improvements to the patient's condition (eg: in regards to the petechiae improving).
    nursel56 likes this.
  8. 0
    sounds like a lazy way of documenting. Each nurse really should document their OWN assessment. I doubt many things remain the same over time.
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    I think it's also a language issue. English is not her first language and she's only been in the US less than10 years. There have been a few comprehension issues due to language so far. Fortunately no harm to patients.
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    Maybe a reminder that all wounds need to be re-graphed q 3 days, or whenever it is your policy dictates. And always document what you see on the day you see it. "reddend coccyx as noted on 5/12/12, reference wound map of same date, is currently being treated with duoderm, which is C/D/I"
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    I don't reference other notes. I will write 'black and blue oopsie', not 'black and blue oopsie as noted on 10/10/10. Can't recall seeing this done. After all, if Julie wrote "black and blue oopsie' on 10/10 and you weren't there on 10/10, how do you know that what she saw was what she charted? Too many times I've found that other people are not consistent, accurate, or thorough in what they chart, so I chart what I see or do and try not to reference others. Think this falls under "standalone" documentation.
  12. 0
    If I refer back to another nurse's note (can't recall a specific incidence of doing that though) it would always be followed with my description of how the area looks at the time I see it. I don't see how you are doing anything wrong, JustBeachyNurse. If you feel it's a language issue rather than a case of her not re-assessing the area you noted on your documentation, your DON or nurse educator should counsel her on that. It could definitely cause her problems down the line.


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