Aide Documentation - Rationale?

Nurses General Nursing

Published

Can some of you wise ones help me with the rationale for aides restricting their narrative notes mostly to documenting care plan tasks they've performed?

I've come up with some dont's, but I'm stuck on rationales.

For example:

  • We never document care someone else gives.

(The nurse put him on the pan.)

  • Assessments, other than objective data requested, are outside your scope.

(He was breathing really hard. Her leg looked infected)

  • Findings when appropriate need to be as specific as possible.

(He didn't get very far on his walk. There wasn't much in the urinal.)

  • Opinions and explanations are not a part of the medical record.

(He smelled like a margarita when he came back. He didn't like what PT told him. He was pissed because he wanted his special mug but dietary took it. I didn't see her light because I was showering someone.)

  • And my favorite: Writing pee and poop is unprofessional, the words are urinate and defecate.

This last one, I don't even know what to call it.

(I took him to the sun deck so he could get some fresh air. Her family came in with their own snacks and soda and talked loud. He was watching Fox news until his wife made him change it. He took communion.)

Soooo. . . what do I use for rationales when I counsel that we don't chart the above statements in parentheses?

1 Votes
Specializes in Psychiatry, Community, Nurse Manager, hospice.

Not sure why aides are writing narrative notes. That's the problem in my opinion.

Aides should have checklists and boxes for data.

15 Votes
On 7/28/2019 at 4:05 PM, FolksBtrippin said:

Not sure why aides are writing narrative notes. That's the problem in my opinion.

Aides should have checklists and boxes for data.

Couldn't agree more, but it's not my call.

2 Votes
Specializes in Medsurg.
On 7/28/2019 at 4:05 PM, FolksBtrippin said:

Not sure why aides are writing narrative notes. That's the problem in my opinion.

Aides should have checklists and boxes for data.

+1 on this.

2 Votes
2 hours ago, Katillac said:

Couldn't agree more, but it's not my call.

katillac - so do you have a role tasked with instructing them on this even though overall it is unnecessary (and some would say inadvisable)? That's too bad. Or, if this isn't part of your official role, I would let it go and let those who made this part of their job description take responsibility for what they write.

What all are they supposed to be documenting?

1 Votes
22 minutes ago, JKL33 said:

katillac - so do you have a role tasked with instructing them on this even though overall it is unnecessary (and some would say inadvisable)? That's too bad. Or, if this isn't part of your official role, I would let it go and let those who made this part of their job description take responsibility for what they write.

What all are they supposed to be documenting?

I'm not technically tasked with the role, but to protect myself and the organization I feel I need to, as this aide's supervisor at times, direct the aide away from inappropriate charting. I say protect myself because the aide often charts details that are very different from what the nurses are charting about the same interventions. Unfortunately, due to the EHR we use, the aides often don't have appropriate check boxes and data fields to use. The PTB tell them "Just check off what you do and fill in the blanks", but depending on how the case manager has set up the care plan, the aide may or may not have anything to check.

So maybe the answer is to just tell the aide not to chart on what the nurses do and when the PTB get around to auditing and giving feedback they will correct what they want to, but I won't be at risk in the meantime.

Thanks for helping me work it through!!

2 Votes
Specializes in orthopedic/trauma, Informatics, diabetes.

I am having some issues now with our aides not being able to write a narrative note. We had a very ugly male pt that was making very sexual comments to one of our aides. I felt that it was not appropriate for me to document what the aide said to me-that's hearsay. I feel like the should be able to document exactly what was said to them. I guess they can email our nurse manager, charge nurse or clinical lead to give a direct account, but it would be nice to be able to see what happens to them, I feel like they can be taught proper documentation

1 Votes
Specializes in ER OR LTC Code Blue Trauma Dog.

Just for fun. ?

17:35 hrs. - Pt. has husband and two teenage children present, but no other abnormalities to report.

18:05 hrs. - Husband reports pt. was very hot in bed last night.

20:30 hrs. - A portable x-ray was ordered and will be done with the pt. on the floor.

21:30 hrs. - Pt. reports large brown stool ambulating in the hallway at this time without any assistance.

6 Votes
Specializes in Surgical, quality,management.
2 hours ago, Crash_Cart said:

Just for fun. ?

17:35 hrs. - Pt. has husband and two teenage children present, but no other abnormalities to report.

18:05 hrs. - Husband reports pt. was very hot in bed last night.

20:30 hrs. - A portable x-ray was ordered and will be done with the pt. on the floor.

21:30 hrs. - Pt. reports large brown stool ambulating in the hallway at this time without any assistance.

#punctuation.

2 Votes
Specializes in Psych, Corrections, Med-Surg, Ambulatory.

How about tell the aide to document just what she does and no more. No descriptions of anything. Eg. Patient was walked in hallway. Pt was given jello. Pt requested pain med and request relayed to RN. Period.

Anything that needs to be described just needs to be promptly reported to you. You need to look at the infected-looking leg. You need to measure the UOP if it looks scant. And she is not allowed to document what anyone else has done.

Meanwhile, is it possible to show examples of her charting to someone and point out to them the contradictions and lawsuit potential?

If there is an incident that needs to be described by the person witnessing it, then anyone can complete an incident report. Then it is up to the risk managers to sift the wheat from the chaff.

2 Votes

Ugh.

I agree I wouldn't like them charting an inaccurate play-by-play that conflicts with the RN's documentation about the same items/care/situations.

Is it an option to talk with their/your supervisor(s) and raise the concern of unnecessary documentation that conflicts with the RN documentation d/t the fact that their training does not prepare them to document as they are and that discrepancies may contribute to increased liability for the facilty? Why take any amount of risk with that when overall it is just not necessary?

3 Votes

I have another "just for fun." The aides where I work don't write notes unless they are filling out an incident report. That being said, this was by far my favorite incident note I have read:

"Patient was found on the floor on her hands and knees, in doggy style position..."

0 Votes
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