Charting"No s/s of infection noted" when pt comatose?

[smartnurse1982]

That isn't accurate,is It?

My supervisor wants me to chart it that way,but I want to tell her they can't talk and some have brain damage,so how can I actually write "no symptoms noted?"

I usually put down..."no signs of infection noted".

That would seem more accurate to me.

Does anyone agree with me?

I just personally think she just likes to pick my notes apart.

We have an assessment/flow sheet that you can check off if there is any infection noted,but she still wants me to write in the narrative notes....I think that's double charting,which I really don't have time for.

[Altra, BSN, RN]

The phrase is poor because it doesn't specify what is being described. No erythema, warmth, edema, excessive drainage ... these are all identifiable parameters.

[blackvans1234]

I have but one thing to say about double charting...

..

http://mvposts.com/wp-content/uploads/2013/05/Aint-Nobody-Got-Time-for-That.jpg

[blackvans1234]

On a serious note, in nursing school they would have us document what we did not see, so we would say ''no erythema, heat, unilateral swelling, purulent drainage noted''

IS this realistic? Idk.

[jadelpn, LPN, EMT-B]

You still need to assess your patient. It would be in your best interest to be a bit more specific. Vital signs stable, skin condition, the areas around any openings/drains/tubes, that you provide care for the tubes, wires, whatever you have. That you turn and reposition every 2 hours.

No s/s of infection is way too broad. Even no symptoms noted--no symptoms of what? Then you get a patient who goes septic, with absolutely no documentation that any catheter, IV site, g-tube---that anything was even assessed, much less cared for. And that can mean no reimbursement should the documentation be reviewed as well.

No one says you have to write out a life story on your patient, however, to take the time to really document an intital assessment could be one of the most important things to do. THEN if your policy permits, you could write "pt turned and repositioned, VSS as follows:-------, patient appears in NAD", and then a little blurb about tubes, wires, whistles....and if patient on a monitor run a strip. Yes, you will hear that no one has time for that, however, make time to cover yourself with complex patients such as you describe.

Even the most "un-complex" patient needs an initial shift assessment when you take over care. Most EMR have lots of little boxes, and it is good practice to even put N/A in what is not applicable. Do not leave blanks if you can help it.

Cutting corners by "no symptoms noted" or "no symptoms of infection noted" is all fine well and good until a patient's condition changes, then "no one" knows "anything" about advising you to document in a broad fashion.

[smartnurse1982]

I'm actually talking about say maybe the trach.

A typical note of mine:

Pt in bed awake with eyes open,Shiley trach # 6.0 intact and patent with no sign of infection noted.

The supervisor wants me to put "no s/s of infection noted".

Now before,I didn't put any of that as there is a check off box on the assessment sheet that says:

Trach patent and intact(I always check that,because they mostly are patent and intact)

and then there are checkoffs for

Stoma site wnL

Or

Stoma site other*

The asterick means you would need to document what you saw,which would be signs of infection.

However,with the stoma wnl box,if I already checked its wnl,why do I still need to write"no s/s of infection noted"?

I forgot to mention,but I'm in homecare.

[mappers]

I think what you are saying is that since a symptom is what a patient tells you, how can you write sign and symptom when the patient is comatose. I would put, "Patient non-verbal and unable to communicate needs...." or something like that.

Tell you superviser, "Thank you for your input. I will take it into consideration," and move on...

[nurseprnRN, BSN, RN]

I hate "charting by exception," which is sort of what your system asks you to do. "WNL" means different things to different people, and in home care, it could even be (wrongly, IMO) patient-specific, as in, "this stoma looks like crap but that's within normal limits for Ol' Joe and we all know it."

As to the rest of it, nobody should graduate from nursing school without being able to recite the signs and symptoms of infection in his/her sleep. Because I hate charting by exception, I see no reason why you shouldn't supplement that check box by saying there are none if there aren't without having to list them all. That at least communicates that you looked.

[aharrellRN]

The phrase is poor because it doesn't specify what is being described. No erythema, warmth, edema, excessive drainage ... these are all identifiable parameters.

Agreed ... Would rather identify pertinent positives and negatives vs. WNL/No S/S noted (as others have said) is varied depending on baseline.

... Alan.

[smartnurse1982]

someone touched on it above. How can i write "no symptoms" when they cant tell me their symptoms?.

There is a box for when a pt is nonverbal. I always check that for the comatose pts,

i always thought when saying "No signs of infection noted" it was understood what the signs were,hence no need to write them out?