progress notes

[cayenne06]

Just curious. I work in LDRP and noticed that all of us seem to have very different charting styles when it comes to progress notes. Some of the nurses seem to chart every detail of every interaction, like "summoned to room by call bell, pt found in left lateral position, desires extra pillow. Pillow obtained from linen closet, pt placed it between her knees. Denies any additional concerns/complaints, advised to call if she needs anything else." I would not have charted ANYTHING about that interaction at all. I would have given her the pillow and called it a day.

Now, my patients are usually healthy pregnant or postpartum women and their babies. Of course ADL things like getting extra pillows might be more important if we are talking about someone with COPD or something. Well, at least I would assume so- I've actually never worked outside of LDRP so I really don't know!

Of course all meds/interventions are charted in the appropriate spot, but I don't usually write an accompanying progress note unless there is a specific issue or related assessment that merits explanation. Like, if I give a multip some oxycodone for her afterpains, I wouldn't chart anything beyond her pre & post pain scale and the dose/route/time etc, unless there was something out of the ordinary. I wouldn't do a progress note about plain old cramping.

I'd love to hear how other nurses use their progress notes! We use electronic charting, if it makes a difference. What do you deem "progress note-worthy?"

[HouTx, BSN, MSN, EdD]

Oh good gravy. Narrative charting needs to reflect the plan of care. It has been this way since Flo lit her lamp. If your narrative charting does not reflect something on the care plan, it is not really needed.

Back in pre-EHR days, I worked with an OCD (officially diagnosed) ICU nurse who "had" to do so much narrative charting, that she had to write in a very teensy longhand... at least three written lines in each blank lines on the form. She was terrified of ever having someone audit her chart and finding something she left out. In a strange way, it worked - it was so hard to read that no one in their right mind, including JC surveyors, avoided her charts like the plague. I have no idea how she coped with the transition to electronic charting - the mind boggles.

She also had multiple other tasks that had to be done at exactly the same time each shift - come heck or high water.... but that's another story entirely.

[turtle0206]

I work in homecare and our notes are scrutinized by Medicare. We were told repeatedly to document as if we were describing the situation to people with no medical terminology education. Medicare will also deny payment if they see that we are not doing any skilled nursing teaching or interventions. So something silly like placing pillows under the knees to alleviate pain can also be documented as teaching and prompting a nonpharm method of pain relief. Do you know what I mean? Being a visiting nurse I must document everything because I am out there alone and god forbid something should happen (I know you've heard) if you didn't document it then you didn't do it. I do agree with you, though, that this practice becomes juvenile and tedious especially when we do checkbox charting as well. Maybe in a hospital setting seeing those extensive notes can be humorous but in homecare its more appropriate.