Can you chart too much?

[Herr_Krankenpfleger]

We had an incident a few months ago where a resident groped another resident. I did all of the typical nursing interventions, including separating the residents and contacting psych and the responsible party. I also made sure I documented exactly where happened in the medical record. Therein lies the problem.

Recently I was called into the DON's office where I was told be more vague about the incident. She stated i should use the term "inappropriate behaviour" instead of stating what happened. I told her that I stand behind my charting because I felt it was my duty as a nurse to make sure I chart accurately as possible. I also do so, because it leaves me a record of what is going on, just incase i have to defend myself. But management is adamant that I be more vague when I leave my notes because they want to make state look problems, instead of handing "it to them on a silver platter"

so my question to you all is...

Is this common nursing practice. I have always been told to be very descriptive when charting and many of my other managers have always told me that I chart really well?

[TheCommuter, BSN, RN]

I was working at a LTC facility several years ago. One of my coworkers decided to chart that a resident was using plastic cutlery to consume his/her meal, and that this same resident had to go to the kitchen to get the plastic fork, knife, and spoon.

During an annual survey, state surveyors read this nurses very detailed charting and decided to tag the facility with a deficiency. If this particular nurse had been more vague with her documentation (or had never documented this incident at all), the deficiency never would have occurred because the incident never would have entered the awareness of the state surveyors.

[maelstrom143]

I was working at a LTC facility several years ago. One of my coworkers decided to chart that a resident was using plastic cutlery to consume his/her meal, and that this same resident had to go to the kitchen to get the plastic fork, knife, and spoon.

During an annual survey, state surveyors read this nurses very detailed charting and decided to tag the facility with a deficiency. If this particular nurse had been more vague with her documentation (or had never documented this incident at all), the deficiency never would have occurred because the incident never would have entered the awareness of the state surveyors.

I'm sorry, but...what that good or bad? Are residents allowed to go into a facility's kitchen on a regular basis in some places? At the facilities where I worked we always made sure to supply the residents w/whatever they needed, thereby no need for them to go into the kitchens, which was prohibited even to us nurses by red/white lines delineating how far in we could approach. I thought their incursions into the kitchens was discouraged for hygiene/safety issues.

[Creamsoda, ASN, RN]

if you directly witnessed it, chart it as you saw it, I don't care what management says. Chart who's hands went where ect. If you did not witness it it, obviously just chart what the patients are stating, in quotation marks. Stating something is "inappropriate" is very subjective and non quantitative.

[luvazsun, RN]

Incident reports are not supposed to be referred to in the patients medical record.

[caliotter3]

I would leave the detailed description of the situation for the incident report and keep it vague in the medical record, like "Ms. Smith reported inappropriate behavior by another resident. Incident report completed; Manager So&So informed."

When in doubt, it never hurts to contact your Risk Management department for instructions.

I have always been told not to refer to any incident report in the charting.