Charting

[nurseshante]

Okay you veteran nurses, I'm new nursing student and had to chart my first foley removel today. My teacher was not impressed. Pls give me your advise. 16fr foley removed today as order. Ballon deflated removing 30ccns. Abd soft non-distented. Patient tol well.

[tokmom, BSN, RN]

Was the balloon intact? What about urine color in the bag and how much emptied? Time of d.c. so you know when to look for retention. That is what I would add.

[nurseshante]

:-) food for thought. Thanks!

[Boog'sCRRN246, RN]

You want include how much urine (also color, clarity, etc) was in the bag at time of removal, how much NS was drawn out of the balloon, if the balloon was intact or not when withdrawn, and that you instructed the patient to notify you of their next voiding after Foley removal. The French is more important, I think anyway, when the Foley is inserted.

[nurseshante]

thanks! I

[gtoko]

Also, charting that you explained the procedure to patient, and how they tolerated the procedure

[Katie5]

Gosh, did you have to shorten almost every word?

[nurseshante]

what!

[rn/writer, RN]

16fr foley removed today as order. Ballon deflated removing 30ccns. Abd soft non-distented. Patient tol well.

You used a lot of abbreviations in your charting and had a bunch of spelling/usage errors. It may be that you wrote it more clearly than you typed this, but if it's the same, that could be what your instructor was referring to.

There are also some key pieces of information missing like urine amount and description and what you told the patient about the next void.

16 Fr. Foley cath d/cd 1045. 30cc ns out [That seems like a lot.] Balloon intact upon inspection. 750cc clear amber urine out. Tolerated procedure. Abdomen soft, non-distended, non-tender. Instructed to use hat in toilet for next void and notify nurse afterward.

[simboka]

I don't remember the phrasing now, but I had an instructor who had a great way to sum up most notes. It was along the lines of, "teaching about XXX done, pt denied questions afterwards.."

But depending on how new you were, I'd have accepted that. But I also would've told you myself some things I would've added so my student would've denied questions afterwards.

[HeatwaveRN]

I would put....

16fr foley catheter removed at 1600 as ordered by Dr. So-and-So. Catheter intact with no clots. Patient denies pain upon removal. 600ml of clear yellow urine in bag. Awaiting post foley removal void. Will continue to monitor patient for urine retention.....

and you can even put your vital signs.

Always put your patient's response to anything you do for them.

[fungez]

Geez, what does your instructor want, the War and Peace charting of foley removal?

I chart "foley dc'd" and the time it came out and that is it. If they have any issues then I will chart that, and I will chart the time they void. I only have so much time in a day and I'd rather spend it doing patient care.