Addendums

sideshowstarlet, BSN, RN · Jul 18, 2022

1 minute ago, JKL33 said:

IMO the whole note is better suited to an incident report (I.e. it is basically an investigation of a situation that someone thought could be a legal risk), but the last two sentences are definitely not appropriate for a patient chart and on top of that would seem to be completely useless information.

Yeah, adding in that English is Nurse Jane's second language seems a little odd.

JKL33 · Jul 18, 2022

1 hour ago, 0121Mednurse said:

The nurse receives A phone call from the Director of Nursing And was told to never chart something like that again Because it makes the facility look Like it’s at fault.

So putting this together it seems like they are telling the staff to monitor a known problem but not document anything about it?

They're being silly if they think that is going to protect them from legal liability. They don't sound qualified to give advice about documentation LOL

toomuchbaloney · Jul 20, 2022

On 7/18/2022 at 10:45 AM, 0121Mednurse said:

As a side note, the nurse was assigned to the unit 3 consecutive nights and each time she received report, she was told to monitor the resident inappropriate behavior with multiple female residents for quite sometime . Nothing has ever been documented . The nurse receives A phone call from the Director of Nursing And was told to never chart something like that again Because it makes the facility look Like it’s at fault.

The facility has a problem with sexual harassmentby a resident, in my view, that they don't want documented. I wouldn't be following their advice... they will gladly throw staff under the bus to protect their stance in this matter. Protect your license with good documentation. Keep your own notes.

chare · Jul 20, 2022

On 7/18/2022 at 11:37 AM, 0121Mednurse said:

This is the progress note a registry nurse wrote. She was assigned to a behavioral unit.

During rounds nurse observed the resident in his room with a female resident. They appeared to be having a personal conversation as the male. resident was observed to be holding her by the arm. The nurse stood at the door way and offered to show the female resident to her room and help her get ready for bed. She made her way out of the room with out incident. Male resident became upset and shouted “stay out of it!”

This is the progress not that was submitted to Nurse Beth.

Quote

This past Sunday, I entered a note in the residence chart and is exactly what I said: RESIDENT OBSERVED IN HIS ROOM WITH A FEMALE RESIDENT HAVING WHAT APPEARED TO BE AN INTIMATE CONVERSATION SINCE THE RESIDENT WAS HOLDING HER ARM. THE NURSE OFFERED TO ASSIST THE FEMALE RESIDENT TO HER ROOM AND HELP HER GET READY FOR BED. THE RESIDENT OF THE ROOM BECAME VISIBLY ANGRY AND YELLED, "STAY OUT OF IT!" THE FEMALE WAS COMPLIANT AND MADE HER WAY OUT WITHOUT INCIDENT.

mtmkjr, BSN · Jul 21, 2022

8 hours ago, chare said:

This is the progress not that was submitted to Nurse Beth.

It seems OP altered the wording of the original progress note by substituting "personal" for "intimate".

"Intimate" is key because

It appears the manager was trying to create a more objective account and explain the subjective language that was used by a person for whom English is not their first language.

I think she did so appropriately. She documented that her addendum was being written after conversation with the registry nurse.

10 hours ago, toomuchbaloney said:

The nurse receives A phone call from the Director of Nursing And was told to never chart something like that again Because it makes the facility look Like it’s at fault.

I can imagine the phone call to the registry nurse was made in order to explain how to use more objective language. Not trying to cover up anything that might have happened, but speaking in generalities to avoid putting the facility at risk. That is reasonable.

As far as the line about not being sure when the registry nurse would be in the community again, I would understand it as an explanation why the DON was making the addendum. She did not know if the registry nurse would be back in reasonable time to make an addendum herself.

toomuchbaloney · Jul 21, 2022

5 hours ago, mtmkjr said:

It seems OP altered the wording of the original progress note by substituting "personal" for "intimate".

"Intimate" is key because

It appears the manager was trying to create a more objective account and explain the subjective language that was used by a person for whom English is not their first language.

I think she did so appropriately. She documented that her addendum was being written after conversation with the registry nurse.

I can imagine the phone call to the registry nurse was made in order to explain how to use more objective language. Not trying to cover up anything that might have happened, but speaking in generalities to avoid putting the facility at risk. That is reasonable.

As far as the line about not being sure when the registry nurse would be in the community again, I would understand it as an explanation why the DON was making the addendum. She did not know if the registry nurse would be back in reasonable time to make an addendum herself.

I'm misquoted in the second quote... those aren't my words.

The manager can chart how she prefers. Addendum notes are not uncommon. Micromanagement of the professional charting of others is a red flag. IMV

mtmkjr, BSN · Jul 21, 2022

5 hours ago, toomuchbaloney said:

5 hours ago, toomuchbaloney said:

I'm misquoted in the second quote... those aren't my words.

The manager can chart how she prefers. Addendum notes are not uncommon. Micromanagement of the professional charting of others is a red flag. IMV

I copied words from your post but it was from within a quote from OP. So it came through as quote from you and I can't ED

toomuchbaloney · Jul 21, 2022

2 hours ago, mtmkjr said:

I copied words from your post but it was from within a quote from OP. So it came through as quote from you and I can't ED

I'm aware... the comment was mostly for the record...

JKL33 · Jul 22, 2022

On 7/20/2022 at 9:29 PM, mtmkjr said:

"Intimate" is key because

It appears the manager was trying to create a more objective account and explain the subjective language that was used by a person for whom English is not their first language.

I think she did so appropriately. She documented that her addendum was being written after conversation with the registry nurse.

That does make at least some sense.

Wow, though. I still think that if an investigation is needed regarding an occurrence, then just write out an incident report and would then be able to include all the investigation that goes along with it, such as what Jane meant by "intimate" and what the actual nature of the situation was and whether Jane speaks good English, blah, blah, blah.

But see, they don't want to do that because they want to not have any pesky incident reports about a supposed non-problem.

And I do suspect they didn't warn her not to use the word "intimate" in charting again, it's quite likely they meant what they said, "don't chart anything like this again..." I.e. about this type of behavior-that-is-not-a-problem.

mtmkjr, BSN · Jul 22, 2022

6 hours ago, JKL33 said:

That does make at least some sense.

Wow, though. I still think that if an investigation is needed regarding an occurrence, then just write out an incident report and would then be able to include all the investigation that goes along with it, such as what Jane meant by "intimate" and what the actual nature of the situation was and whether Jane speaks good English, blah, blah, blah.

But see, they don't want to do that because they want to not have any pesky incident reports about a supposed non-problem.

And I do suspect they didn't warn her not to use the word "intimate" in charting again, it's quite likely they meant what they said, "don't chart anything like this again..." I.e. about this type of behavior-that-is-not-a-problem.

Maybe it's simply "Let's not create a problem where there isn't a problem"

HiddenAngels · Jul 22, 2022

I don’t like the idea of any of this. It goes against so many measures and laws already in place (False socumentation, privacy, code of conduct, professionalism) If you feel the need to add something to a legal document. A medical record is a legal document. Then you need to add your own note. It should not be an addendum written or added to someone else’s note pertaining to their observations experiences and assessments.

HiddenAngels · Jul 24, 2022

On 7/22/2022 at 2:20 PM, HiddenAngels said:

I don’t like the idea of any of this. It goes against so many measures and laws already in place (False documentation, privacy, code of conduct, professionalism) If you feel the need to add something to a legal document. A medical record is a legal document. Then you need to add your own note. It should not be an addendum written or added to someone else’s note pertaining to their observations experiences and assessments.