Charting Shame

It sounds like you learned a lesson and it was an instance where nothing bad happened to your patient. Be kind to yourself. We are so inundated with charting details that sometimes things can slip through. I know that when there are 16 entries for where the patient has edema, I haven't specifically gone back to assess the ankles vs feet vs legs for moderate, mild or trace. Sometimes I'll just lump it all together, or even just skip it. One blood pressure reading, when there are normal reading before and after, is not a big deal. Patient position, movement, cuff position, all of these things can affect a single reading. Don't worry about it. 

Yikes, yea don’t beat yourself up it’s done, but one thing tho, you don’t want to give meds without being sure about those vitals.

Not funny yet kind of funny charting oops! I have seen in the SNF I used to work for. A gentleman on neuro checks post fall who was consistently charted as having pupils equal and responsive...kind of impossible as he had a glass eye.  Another man who always seemed to have clear lung sounds throughout despite having had a lobectomy, amazing how that works! 

My all time favorite though was back in the days of paper charting, everybody just kept checking the same boxes and writing the same thing as the previous person who charted. The huge paper charting binder was not cleaned up in a timely manner. This resulted in a woman who had miraculously  consumed 100% of all meals for 3 days after she had died before it was caught. 

Nurses are not the only guilty party either. I can't tell you how many provider notes I read with details of an assessment that somehow was magically performed from the doorway or even the hall outside the residents room. 

Being a wound care nurse, I find documentation by providers saying stuff like skin is "pink" (on an African American with wounds).  No rashes/lesions (again, rashes or lesions on the person). Some are adding to 'areas seen'. And of course the ER nurses that chart skin as "intact" (despite admitting wounds). The normal stuff.   Pulses on amputees. Or the days of charting "dressing covering site" (nobody changed the dressing??!!??)

1 hour ago, kbrn2002 said:

Not funny yet kind of funny charting oops! I have seen in the SNF I used to work for. A gentleman on neuro checks post fall who was consistently charted as having pupils equal and responsive...kind of impossible as he had a glass eye.  Another man who always seemed to have clear lung sounds throughout despite having had a lobectomy, amazing how that works! 

My all time favorite though was back in the days of paper charting, everybody just kept checking the same boxes and writing the same thing as the previous person who charted. The huge paper charting binder was not cleaned up in a timely manner. This resulted in a woman who had miraculously  consumed 100% of all meals for 3 days after she had died before it was caught. 

Nurses are not the only guilty party either. I can't tell you how many provider notes I read with details of an assessment that somehow was magically performed from the doorway or even the hall outside the residents room. 

LOL! Yes this, ha ha! You forgot the pedal pulses with the bka 

2 hours ago, CalicoKitty said:

Being a wound care nurse, I find documentation by providers saying stuff like skin is "pink" (on an African American with wounds).  No rashes/lesions (again, rashes or lesions on the person). 

I’ve seen the opposite, I’ve seen some constantly charting AA as dusky. I’m like huh?