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Discussion

charting error???

I am orienting at a home health agency. I seen my second patient solo today. She had told me she had donor skin removed from under a small dressing. I charted this, as I could not remove the new bandage without new wound care orders and patient stated that new bandages were to stay on until follow up. My prereceptor told me to remove that from my charting before I closed my chart (electronic charting). Am I wrong to chart what she told me even though I wasnt able to verify what was under dressing? Also called doc with no return calls several times for orders. Locked my documentation and will add order later if given. Was told I was wrong in this also. Told to leave visit open til order obtained.

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    • Featured Replies

    I finalize all charting at end of day making sure to state no return call recieved from MD. The next day I follow up and use a communication note to document that I followed up.

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    Um why did they tell you to remove it? Basic nursing documentation includes quoting what the pt says if it is pertinent to the case. I believe you would be covered if you quoted what the patient said had happened then document you are unable to assess wound due to non-removable dressing in place dry and intact. then call the md to get/confirm orders.

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    • Author

    Thanks for the comments, I left it in due to learning what patient says should be charted. I've been an lpn for 2 decades and never heard that I shouldn't document those things. Was curious of Medicare guidelines stating if I dont observe it I cant chart its there.

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    • Experts

    I don't understand why you were told to remove the charting concerning the wound you did not observe. I would have charted that the dressing was left intact and why, as you did. Far worse, is charting the opposite and then finding out at a later date that you were REALLY wrong. And the same goes for charting verbatim what the client tells you. Always a good idea to do this, even if only on a communication note to accompany the day's regular note. I would be wary about taking direction from the agency supervisors in the future. Sounds like they may be playing loose with charting and you don't want to get too involved with those practices.

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    Best practice suggestion; complete you documentation with the completion of the visit. I bet your software has a way for you to document additional notes when the doctor finally returns your call and provides an order.

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