Nursing notes & legal stuff

Nurses General Nursing

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Specializes in Pediatrics.

Looked for some info here but didn't find much, but if you can point me to another thread please do.

A funny meme on FB about the phrase "will continue to monitor" started some heated conversations in the comments section.

I'm concerned now that I need to change my progress notes. I was taught by my preceptor to put this ridiculous phrase at the end of every note but some say it opens you up to more questions in court. Some say, "it's the end of your shift, you're not monitoring any more!" but technically I usually write my notes between 3 and 5pm for 7a-7p.

The thing is, it's just filler. Obviously I'm going to monitor my patient, so I shouldn't put this in my note, right?

I'm concerned too that there might be other things I write consistently that should be removed.

Any legal nurses want to shed some light?

Example: Pt transitioned to open crib, temps stable. Witnessed three bradycardic events while pt at rest, self corrected. Pt taking full PO feeds x2 so far. Notified Dr. XYZ of gastric residual >50% x1, verbal orders received and carried out. Residual stable at this time. Peri care as ordered, buttock excoriation resolving. Parents at bedside and active in care for one round. All questions answered and updated on plan. Will continue to monitor.

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I'm no legal expert, but continue to monitor in your note above seems unecessary, rest of the note looks concise though. I used to use "continue to monitor" all the time when I was writing structured not that you need a plan section for because sometimes that's all I had to say for that section. But now I do narrative it doesn't seem necessary.

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I dont really write much in the nurses notes or progress notes. Unless its is something that doesnt have some boxes and words that i can click in the assessments section and some other forms that are pre-made on the charting software. Another nurse told me to do this because he said I shouldn't under-document but at the same time I shouldnt over-document because lawyers are very good at english language usage. What you say can and will be used against you...

I think there should be a box for "continue to monitor" or something of that category somewhere in your charting program at your facility.

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I don't use that phrase in my notes, although some of my peers do. I'm of the school of thought that my exact job is to monitor the patient on an ongoing basis. Why state the absolute obvious?

To be sure, it is a generic filler, unless you caveat what exactly you will be monitoring. The diaper rash? The A/B/D events? Everything under the sun?

I too leave nursing notes for the things that I can't tick on boxes. And in your case, in NICU, the job expectation is that you will be watching the Tele monitor for spells, you will be assessing that diaper rash q diaper change, you will be monitoring for any changes, yada, yada, yada. That's in policy as part of your job.

I don't think the phrase is going to land you in hot water, per se. It's pretty benign. But it seems superfluous. And I'm always against superfluous charting!

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If I write continue to monitor, I try to close my shift with a comment with the progress of the things I was monitoring. Ie pt still in a fib 110-117 but asymptomatic. Will alert night staff or something. I tend to equate my charting with a book and I don't want to leave "plot points" unresolved for my reader. I'm a nerd, I know

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Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.

I never write "will continue to monitor" unless, on the rare occasion I know for a fact I will go and write another note or an addendum that details the follow up results.

I was was told that this phrase opens one up to legal scrutiny.

However, many nurses do use this phrase.

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Why do you need to state will continue to monitor? It sounds like you are not taking any action on the issues but just monitoring. I don't put any notes in unless I need to explain additional information and then I put the action I took for the issue. I don't need to state the patient is stable, their vital signs show that. It seems redundant and double charting to me. If the diaper rash is not listed under skin issues, then I add it in, but I don't put a note. Treating the diaper rash should be shown in meds you gave.

I only put notes in for situations that can't be put in my box charting. Then I put in what action I took to rectify the situation. It is my job to monitor the patient. I guess I don't need to state it.

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Specializes in ICU.

I agree with above posters that I wouldn't really use the 'will continue to monitor' in the note you wrote. I do, however, use the phrase in my notes. Mostly in situations where I feel like I need orders from the doctor but don't receive them. For example on an ICU patient:

"Patient noted to be awake on ventilator and agitated with RASS +3, leaning forward in bed and attempting to self extubate. Attending called, notified that patient is not adequately sedated on max dose Precedex per order, no new orders received. Attending states he is unable to come to the bedside at this time to evaluate patient. Attempts to orient patient to situation unsuccessful. Bilateral wrist restraints in place. Will continue to monitor."

Really just a CYB for me that I have identified a problem, the doctor has failed to give me orders that I feel that I need, and that I have done my due diligence at attempting to fix the problem and am still monitoring it despite the fact that I am unable to fix things with what I'm working with. Aka the liability is on the doctor here, not me.

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Specializes in Pediatrics.

Thanks! I guess I understand better when to use it. It's just how I was taught but I'm learning not everything I was taught is correct ;)

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Specializes in Pediatrics.

Where I'm from we're required to write a progress note, or shift summary basically, so a lot of the time, what's in the note is redundant because there is nothing to say other than there were no issues with the patient. It's annoying, but it is what it is.

Most of my notes are the same because of this, they are essentially a template.

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I posted this as a reply in another post but think that it's more appropriate here.

My previous hospital was using EMR since at least 2009 when I was in nursing school, I started working there in 2011 and we were trained to chart by exception, our EMR was rather detailed though. We would of course chart if something happened during the shift, or if a physician was called but that was about it. Enter my new hospital in a new state, nurses notes are loosely expected q2h or at least staff feels that way. These notes on nights are mostly that the pt is resting in bed, respirations even, or if the pt is medicated for pain. I get that that is an exception except I work on a med-surg floor, so not really and the eMar requires you to document the pain level, so it just seems redundant. Now if something happens, injury, change in condition, code, rapid response etc, I will note the event down to the minute to the best of my ability and it will be very detailed but resting in bed eyes closed is too much imo.

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Specializes in Psych, Addictions, SOL (Student of Life).

I once had a surveyor form the department of health reading my nursing notes that all ended "Will continue to monitor." She asked "What are you monitoring?" I have learned to state specifically what being monitored, for what and how long. In psych we are always monitoring something, behavior, safety, efficacy of medications, progress in treatment etc...

A typical note when I do wound care would include a description of the wound type of dressing used and end with will continue to monitor wound for progress or infection."

All my behavior notes generally end with "Will continue to monitor behavior for safety every 15 minutes ,,,,,,,,,,,,bla, bla, bla.

Hppy

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