Documentation Questiion

I don't work in home health, but I have not seen a documentation system that allowed or encouraged references to another clinician's assessment. Various electronic systems have the ability to copy/paste ... but when you use that function you are using it to represent that wording as your own observation, not simply stating that what you observe is the same as what someone else observed.

As you note - there is likely to be some change in the appearance from day to day anyway ...

I'm not sure how big a deal this is ... but it just doesn't sound like something I would do.

We do handwritten paper charting. I have a certain style of writing my narratives. She copies a lot of the specific phrases that I use which to me is not an issue if appropriate. (like "resting quietly, eyes closed, respirations equal and unlabored; side rails up and brakes in locked position). Sometimes you read a chart and get an idea of how to phrase something. But it just seems odd to me to not write out your OWN observations when charting an assessment and simply writing a reference to someone else's assessment (red mark on leg as noted in nursing notes from ).

Just wanted to make sure I am documenting correctly by writing out my own observations each shift

I agree ... I've picked up certain verbage that I like from others nurses with whom I've worked. I was using the copy/paste example as an illustration of that.

And as I said, I agree, I would not reference another clinician's observations as my own.

i once worked directly with a hospital administrator who audited my work (lucky me!) --- it was one of those random things for quality control.

since day one of nursing school, i've always been told to always be precise with my documentation no matter how busy i get in order to protect my license. so when i was audited, the administrator was surprised that someone so young was doing way better than the "experienced" nurses; mind you, i've always debated with myself if i was doing way too much since my senior nurses would tell me that i was too "precise."

after being audited --- i was scared out of my mind --- and the administrator being happy with my work, i felt more confident that i was doing the right thing to represent my company if jcaho (the joint commission) happened to stumble across my work.

the administrator then had me make a booklet to help refresh my colleagues on how to document properly. i was also given expressed directions that if anyone tried to give me lip to contact the administrator's direct line so s/he can come down and teach the unit personally. *ouch

justbeachynurse

i don't think you're making yourself work hard. you're doing the right thing. as for the other nurse, i think she just needs a friendly re-education; just let her know that in order to protect her license she ought to use her own findings (if there is definitely a change in the patient's status). also, it would help a lot to see if there were improvements to the patient's condition (eg: in regards to the petechiae improving).

sounds like a lazy way of documenting. Each nurse really should document their OWN assessment. I doubt many things remain the same over time.

I think it's also a language issue. English is not her first language and she's only been in the US less than10 years. There have been a few comprehension issues due to language so far. Fortunately no harm to patients.

Maybe a reminder that all wounds need to be re-graphed q 3 days, or whenever it is your policy dictates. And always document what you see on the day you see it. "reddend coccyx as noted on 5/12/12, reference wound map of same date, is currently being treated with duoderm, which is C/D/I"

We do handwritten paper charting. I have a certain style of writing my narratives. She copies a lot of the specific phrases that I use which to me is not an issue if appropriate. (like "resting quietly, eyes closed, respirations equal and unlabored; side rails up and brakes in locked position). Sometimes you read a chart and get an idea of how to phrase something. But it just seems odd to me to not write out your OWN observations when charting an assessment and simply writing a reference to someone else's assessment (red mark on leg as noted in nursing notes from ).

Just wanted to make sure I am documenting correctly by writing out my own observations each shift

I do home health with a little one too. I personally like to document what I see, not what someone else sees. I think I write good notes (thorough, very descriptive--20 years in EMS will do that to you, LOL) and when I read back over other nurses notes, I see a couple of them using phrases that I do. I'm certain that they are their own observations, just "my" verbage.

I don't know if our way of documentation is "right", but I sure feel a whole lot better with the very complete way you and I seem to chart. JMO....