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Critique my documentation?

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by KEL2BanRN KEL2BanRN (Member)

This is my second day of charting. We're at a nursing home and have same resident each week for now. This is for practice, we will be charting in the actual chart next week. How does this look/sound?

11/09/07 0710 Supine in recliner, resting /c eyes closed. Aroused easily, A&O x 3. T 97.9, P 78, R 20, BP 122/65. PERRL 3mm. AV fistula L upper arm bruit present, thrill bounding. Resps shallow, even, unlabored. Skin on face and chest pink, warm, dry & intact. Chest symmetrical. Lung sounds clear A&P bilaterally. Pulse Ox 98% on room air. Abdomen soft, round, non-tender on light palpation. Bowel sounds present x4. LBM 11/8/07, large, soft, brown. Ap pulse 78, irregular. States "An aide bumped me on my pacemaker yesterday and it really hurts. It hasn't felt right since then." C/O pain 3/10 over pacemaker site. Reported to charge nurse. UEx2 pale, warm, dry. Radial pulses thready. L hand shows 1+ pitting edema. Denies paresthesia and pain, no paralysis noted in UE. Hand grasp = bilaterally. Ankles purple, cracked, peeling from ankles approximately 20 cm up and around the circumference of both legs. Tibial and pedal pulses non-palpable bilaterally. LE show 2+ pitting edema bilaterally. Cap refill

0900 Up in w/c. Feeding self independently. Denies needs. Call light in reach.-------J Doe SN

1100 Participating in activity in dining hall. Denies needs. Report off to charge nurse. J Doe SN

Nrs_angie, BSN, RN

Specializes in Med-Surg, Tele, Vascular, Plastics. Has 2 years experience.

This is my second day of charting. We're at a nursing home and have same resident each week for now. This is for practice, we will be charting in the actual chart next week. How does this look/sound?

11/09/07 0710 Supine in recliner, resting /c eyes closed. Aroused easily, A&O x 3. T 97.9, P 78, R 20, BP 122/65. PERRL 3mm. AV fistula L upper arm bruit present, thrill bounding. Resps shallow, even, unlabored. Skin on face and chest pink, warm, dry & intact. Chest symmetrical. Lung sounds clear A&P bilaterally. Pulse Ox 98% on room air. Abdomen soft, round, non-tender on light palpation. Bowel sounds present x4. LBM 11/8/07, large, soft, brown. Ap pulse 78, irregular. States "An aide bumped me on my pacemaker yesterday and it really hurts. It hasn't felt right since then." C/O pain 3/10 over pacemaker site. Reported to charge nurse. UEx2 pale, warm, dry. Radial pulses thready. L hand shows 1+ pitting edema. Denies paresthesia and pain, no paralysis noted in UE. Hand grasp = bilaterally. Ankles purple, cracked, peeling from ankles approximately 20 cm up and around the circumference of both legs. Tibial and pedal pulses non-palpable bilaterally. LE show 2+ pitting edema bilaterally. Cap refill

0900 Up in w/c. Feeding self independently. Denies needs. Call light in reach.-------J Doe SN

1100 Participating in activity in dining hall. Denies needs. Report off to charge nurse. J Doe SN

Just a few things that I noticed. Be careful on the abbreviations that you use. Some have been rejected by JCHAO. Ask for a list of currently accepted abbreviations. One that I believe has been rejected is the use of UE for upper extremities. Also it sounds like there is a pressure ulcer or decubiti of some sort under the coccyx dressing. I would have removed the dressing and looked at the wound and include that assessment in the note. By the way, I can't believe they still make you do these long, redundant nursing notes in school. I always hated doing them. In the real world, you have already charted these assessments on your flow sheet. The nursing notes /progress notes are only for something out of the ordinary that doesn't fit into the flow sheets... no one rarely has time to read long, redundant nursing notes. But school is school and its kinda like basic training before you go to war!

ex1140

Specializes in Mental Health. Has 8 years experience.

"By the way, I can't believe they still make you do these long, redundant nursing notes in school"

I agree before I could get through half of the note my impression was...boy this is too much information. ;)

...but...since you are a student you get an A... :)

Overall looks great, one thing I would be careful of, is as someone else said, too many abbreviations. ALso, try to do head to toe, abnormal, before normal. So, I was surprised to see the wound dressing listed at the end. I would list vitals, then dressing change if that was done, then go into body systems, but just personal preference.

Just a few things that I noticed. Be careful on the abbreviations that you use. Some have been rejected by JCHAO. Ask for a list of currently accepted abbreviations. One that I believe has been rejected is the use of UE for upper extremities. Also it sounds like there is a pressure ulcer or decubiti of some sort under the coccyx dressing. I would have removed the dressing and looked at the wound and include that assessment in the note. By the way, I can't believe they still make you do these long, redundant nursing notes in school. I always hated doing them. In the real world, you have already charted these assessments on your flow sheet. The nursing notes /progress notes are only for something out of the ordinary that doesn't fit into the flow sheets... no one rarely has time to read long, redundant nursing notes. But school is school and its kinda like basic training before you go to war!

Hm, My CI is the one who told me to use UE for the upper extremities. Is there a list somewhere of abbreviations we can't use? As for the PU dressing, I am not to remove it - it was just put on that morning and I'm just supposed to assess the dressing at this point.

"By the way, I can't believe they still make you do these long, redundant nursing notes in school"

I agree before I could get through half of the note my impression was...boy this is too much information. ;)

...but...since you are a student you get an A... :)

LOL Thanks. I guess what they're doing with us right now is getting us used to doing full head to toe assessments and learning how to document. I'm really lost on how to document, and I wonder just how everyone automatically knows how to do it...? I have no idea how to word things.

Overall looks great, one thing I would be careful of, is as someone else said, too many abbreviations. ALso, try to do head to toe, abnormal, before normal. So, I was surprised to see the wound dressing listed at the end. I would list vitals, then dressing change if that was done, then go into body systems, but just personal preference.

Could you be more specific on the abbreviations? So far I've used all of those before and my CI has said it was fine. In fact he's the one who has told me to use most of them. I did do head to toe, and I stick in abnormal things where they happened, kwim? The reason the coccyx dressing was at the end is because she's in LTC and I helped her to the restroom where I helped her undress and did her bath, etc, that's when I assessed her coccyx dressing. It was one of the last things I did before helping her dress and getting her settled. I don't think I'll ever get this stuff right. LOL

Nrs_angie, BSN, RN

Specializes in Med-Surg, Tele, Vascular, Plastics. Has 2 years experience.

Hm, My CI is the one who told me to use UE for the upper extremities. Is there a list somewhere of abbreviations we can't use? As for the PU dressing, I am not to remove it - it was just put on that morning and I'm just supposed to assess the dressing at this point.

JCAHO issues the approved abbreviations to each hospital annually I believe... the reason is because abbreviations are used incorrectly and they don't always mean the same thing every where you go... also the chance of errors is higher with some. Im not saying your instructor is wrong... Im just giving you info. Also perhaps your instructor is letting the abbreviations slide. Abbreviations were used for soooooo many years and it is such common practice that your instructor may not have a problem with using them. BUT SOLEY FOR YOUR INFORMATION, JCAHO HAS REJECTED THE USE OF CERTAIN ONES DUE TO ERRORS. Ones that I can specifically remember are:

CC or cc (one means chief complaint and one means cubic centimeters, mL is now to replace cc)

OD (right eye) OS (left eye) and OU (both eyes) these are no longer acceptable because the left can be mistaken for the right, and vice versa.

There are many others... these are just the couple I can remember without a list.

Again, some people and docs may still be using them... its such common practice... but JCAHO warns that we should not do it in our charting.

Besides all that.... I think your note was fine... you pretty much gave the head to toe assessment... if something was abnormal you also wrote what you did to intervene... and you made it clear that the patient was safe by referring to call bell in reach and patient denies needing anything. You pretty much got the hang of it. It is a good note. Don't stress about it too much because like i said earlier... you wont be writing long redundant notes in the real world (when you are out of school). It's just something they make you do in nursing school so the instructors can evaluate if you know how to do a head-to-toe and if you know what abnormal looks like.

I hope I made better sense this time... let me know if ya have more questions.

JCAHO issues the approved abbreviations to each hospital annually I believe... the reason is because abbreviations are used incorrectly and they don't always mean the same thing every where you go... also the chance of errors is higher with some. Im not saying your instructor is wrong... Im just giving you info. Also perhaps your instructor is letting the abbreviations slide. Abbreviations were used for soooooo many years and it is such common practice that your instructor may not have a problem with using them. BUT SOLEY FOR YOUR INFORMATION, JCAHO HAS REJECTED THE USE OF CERTAIN ONES DUE TO ERRORS. Ones that I can specifically remember are:

CC or cc (one means chief complaint and one means cubic centimeters, mL is now to replace cc)

OD (right eye) OS (left eye) and OU (both eyes) these are no longer acceptable because the left can be mistaken for the right, and vice versa.

There are many others... these are just the couple I can remember without a list.

Again, some people and docs may still be using them... its such common practice... but JCAHO warns that we should not do it in our charting.

Besides all that.... I think your note was fine... you pretty much gave the head to toe assessment... if something was abnormal you also wrote what you did to intervene... and you made it clear that the patient was safe by referring to call bell in reach and patient denies needing anything. You pretty much got the hang of it. It is a good note. Don't stress about it too much because like i said earlier... you wont be writing long redundant notes in the real world (when you are out of school). It's just something they make you do in nursing school so the instructors can evaluate if you know how to do a head-to-toe and if you know what abnormal looks like.

I hope I made better sense this time... let me know if ya have more questions.

Yes, thank you!! :)

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