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?
My favorite is when I see BKAs that have pedal pulses charted when that limb is longer there.
I've seen this also.
Maybe if the patient has phantom pain in the amputated limb, then it can actually produce a pulse too. Personally, I have never been able to locate that pedal pulse location....perhaps I should work on my assessment skills!
I hear you. So many times I have looked at the assessment sheet and wondered where the admitting nurse left her eyes when she was doing the assessment. I, like you, will find all kinds of scars, sores, etc when the assessing nurse has stated on the sheet that the person had no sores, no scars, nothing. Yeah right...argggh!
We have a nurse who routinely charts the patient performs thier Incentive Spirometer
X10 with every hours documentation- Even the intubated patients. NOW THAT'S DEDICATION to affix the I.S. to the ETT and make the patient do 10 breaths!!!-What a nurse!
We have another nurse who charts the quality of her chest tube drainage as "cherry". Not sanguineous or serosanguineous or even bloody. I wonder if she charts her infected wound drainage as "pistachio" or "lemon"?
I loved hearing your thoughts, especially Thornbird's.
I frequently get in report "lung sounds clear but diminished" It makes me wonder two things: 1. Did you really listen to your patient? and 2. Do you own a good stethoscope and know how to use it?
Also thanks for the reinforcement about the "Impaired gait" score. While I can see that the non ambulatory patient would technically have an impaired gait, if they are bedridden, or a bilateral amputee, there is no gait, so how can you say it is impaired when it is nonexistent?
I'm sorry, I must be dense this morning........what's wrong with clear but diminished breath sounds? You don't hear rales, you don't hear rhonchi, you don't hear wheezing, but the bases are not inflating as much as they should/could........clear lung sounds but diminished in the bases.
I work with an NP who often will "dispose" :nono:of the chart notes on a new pt. She chooses to word things her own way-therefore reducing the amount of time needed to spend on the pt. This is my ultimate charting pet peeve!
Nurses who chart that skin integrity is ok will talk about the decub being treated in report. Interesting I think. Often find that tasks not done at all are charted as having been done and that skin is intact and clear when there are wounds, sores, scabs, or even surgical wounds. Reasons for inaccurate charting are carelessness, and laziness. Nurses know that if they chart about a skin tear that they observed, then they must do follow up. It is much better to leave anything and everything to another shift to handle, because they can't be bothered. You can talk to the individual about it or you can bring up the matter to a supervisor, but don't expect anything to change right away. Laziness is a difficult habit to break in another person.
Medic2RN, BSN, RN, EMT-P
1,576 Posts
I've seen this also.
Maybe if the patient has phantom pain in the amputated limb, then it can actually produce a pulse too. Personally, I have never been able to locate that pedal pulse location....perhaps I should work on my assessment skills!
