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?
When I was a nurse educator I recommended strongly that any time the aides needed to write a narrative note, they go to the licensed nurse for assistance. This was to avoid the types of problem you describe. Of course, you have to have management's and the RN's support on that one.
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..."
They need to use more professional language. Tell them next time to write “ in the rear entry position.” ??
Golden_RN, MSN
573 Posts
When I was a nurse educator I recommended strongly that any time the aides needed to write a narrative note, they go to the licensed nurse for assistance. This was to avoid the types of problem you describe. Of course, you have to have management's and the RN's support on that one.