Charting Issues that Really Bug Me!!!

[al7139, ASN, RN]

Hi all,

I just have to get this out!

I get really irritated when I see assessments on patients that are not accurate! It is a personal irk of mine.

Heres an example (and one that absolutely drives me NUTS!)

We have a rating scale for fall risk patients, where there is a number assigned to each point and the score is totalled after each is answered.

I frequently see charting in the criteria "Impaired gait" where a nurse will give a score that means the patient has an impaired gait when either 1: the patient is bedridden (and has been for years), or 2:they have bilateral amputations making it impossible for them to walk.

How is it possible for these patients to have an impaired gait when they cannot ambulate?!?!

The proper rating is 0, since they are not walking, therefore do not have a "gait" to be impaired.

Drives me crazy!

Another one is when I am told a patients skin is intact, and then I find a lovely suppurating decub on their backside, and am told the patient didn't have that when they recieved report! It really makes me wonder how many nurses are doing thorough assessments on their patients! This one just plain ticks me off, because it is poor nursing.

Anyone else have stuff that drives them nuts about charting/assessments?

Amy

[ProLogic]

Maybe you should tell them to change their ways.

[locolorenzo22, BSN, RN]

Do YOUR job to the best of your ability....do they really think that if the nurse before you notes a stage 1 and you note a stage 4, maybe the other nurse has a problem with assessing?

[RN1982]

I hate when people don't chart at all. I also hate when people say they did something and don't chart it.

[DusktilDawn]

My favorite is when I see BKAs that have pedal pulses charted when that limb is longer there.

However, in response to the OP's original concern, what I find is that when facilities implement a measurement system whether it is risk for falls or for skin breakdown, there tends to be a breakdown when it comes to adequately educating the staff on how to properly use that system. Also, there tends to be poor follow-through in evaluating the staff after these systems are implemented to ensure that they understood what was taught and that they are able to appropriately rate patients on these scales.

[crissrn27, RN]

When I took over MDS at a LTC place a few years ago, I found on the careplans for everyone in the building to have a pedi once every three months. Nice huh? Especially since at least 25% where single or double amputee's.

[TazziRN, RN]

I agree with the one about the decub, but an amputee or bedridden pt does have an impaired gait. The gait is not normal, therefore it is impaired.

We have to evaluate the gaits of home health pts, and those fall under "abnormal gait" and "decreased endurance". "Impaired" does not mean there is room for improvement, it means abnormal.

[RN1989]

With the new CMS regs on not all the stuff they won't pay for if it is hospital acquired, these nurses are going to have to do a better job or they'll likely get canned. It is going to be even more important to assess and document accurately on admit and transfer. Once the hospital loses a bunch of money on nurses missing these types of things, it's going to get ugly.

[ONCRN84]

I really love it when the neurological assessment is within normal limits...

on a quad.

[RNperdiem, RN]

Much of our paperwork is "fluff". The nursing careplan printed, signed, put on the chart and never looked at again(except in chart audits) falls under that category. If errors occur there and do not affect patient care, I would ignore it.

The critical things to get right are things like vital signs, blood glucose, lab values, intakes and outputs, cardiac rhythms and neuro changes.

[rita359]

I think some of this is lack of education when new forms are introduced. Forms just seem to show up. There isn't even written examples on bulletin boards on how to use the form. Example would be the impaired gait. If patient is unable to walk there should be a seperate box for that if one does not expect those people to be included under impaired gait which obviously they are as they cannot walk.

[Thornbird]

What bugs me: everyone's LS are "clear but diminished"......the "scab" is a necrosis.....the advanced Alzheimer's pt is "A&O"......."3+ pitting edema, good CSM".........made-up abbreviations nobody can understand.

1st poster was correct about the Fall Risk Assessment, there is a value of 2 for the non-ambulatory pt and none of the other points should be awarded. I hate when supervisors and MDS coordinators fill out these and the Braden scales. They don't know the patient, are way off on the score and the tool becomes useless.