Documentation "No-No's"?

[elb252]

Alright (experienced) nurses,

I need your assistance. I know that when documenting, there are certain terms that are considered taboo for writing out; ie, "Mr. X hasn't had a bowel movement in the past 9 shifts; will follow up with physician for possible *impaction.*" I know that "impaction", or the infamous "I" word is considered unfavorable in charting.

Another example might be, "After contacting Mrs. Y's POA regarding her fall, incident form was completed." For legal reasons, incident reports are never mentioned in documentation.

So, can anyone help me think of any other examples?

[eslvn]

I beleive we are not to use the word "agitated/agitation" other than that I dont know and am curious myself.

[caliotter3]

There is a list of unacceptable abbreviations and terms that many facilities will not let you use. You can find the list on the JCAHO site.

[AngelofLTC]

It drives me crazy when another nurse uses my name. In our facility (and when we were taught in school) we use "nurse or LPN on previous shift" isntead of a name. I will also document "this writer" instead of "I". Soooo my progress note would say " this writer received report from RPN on previous shift...." I hope this helps.

[AngelofLTC]

I have been told by my ADON that my documentation is great...

[Hospice Nurse LPN, BSN, RN]

It drives me crazy when another nurse uses my name. In our facility (and when we were taught in school) we use "nurse or LPN on previous shift" isntead of a name. I will also document "this writer" instead of "I". Soooo my progress note would say " this writer received report from RPN on previous shift...." I hope this helps.

Funny how different facilities are. We are SUPPOSED to write the name and title of the person in our notes. Ex:

"Obtained n/o for ativan 1mg Q 6 hr PRN for anxiety. First dose was given s incident @ 1325. Informed my relief, AngelofLTC, LPN of n/o.

Hospice Nurse, LPN"

[AngelofLTC]

Ok I should clarify Being computerized... our name and title would be automatically attached to the note and for this reason there is no need to sign " AngleofTLC, RPN"

[TheCommuter, BSN, RN]

1. Never document that a patient / resident is in pain unless you are also charting about an intervention that you carried out to help with the pain (medication, distraction, repositioning, deep relaxation, etc.).

2. Never document that the patient / resident is threatening suicide unless you are also charting that you have notified the physician, family, responsible party, social worker, case manager, and any other pertinent individuals.

3. Never document that the patient / resident has a newly discovered wound or skin tear unless you are able to chart that a treatment was initiated (daily dressing changes, topical ointment, leave open to air, and so forth).

4. Never document that the patient / resident has new-onset 4+ pitting edema, lung sounds with crackles, pale complexion, and difficulty breathing unless you are prepared to document what you did about it (notified MD, obtained order for Lasix IV push, Fowler's position, daily weights, diet changed to cardiac no added salt, etc.).

5. Never document any critical lab value without charting that you notified the attending physician. Your hard-earned nursing license might get referred to the state BON for investigation if the resident has a potassium level of 6.1, suddenly dies of cardiac issues, and the critical result was never addressed.

6. Never document any finding, assessment, or observation that is grossly abnormal unless you can also chart that you notified the doctor, implemented any new orders, and implemented appropriate care.

[Hay Nars, RN]

It's okay to use the word I in charting.

[Florence NightinFAIL, BSN, RN]

I was told not to chart times - ex. VS times and med times - because most of the time when we chart, we don't have the pts MAR or flowsheet in front of us - so we might not write the EXACT time. But that was from a co-worker although I could see her point - I would write 1249 in the MAR and chart 1245. So potential for problems there.

[Whispera, MSN, RN]

Don't use words that are open to interpretation, such as "agitated" or "in pain." Instead use objective words to tell how you knew the person is agitated or in pain (writing around, screaming, scale of 1-10, etc.)

Do chart things you assess that need interventions, along with what you did about it. If you don't chart what you assess, then it can be assumed you didn't assess and didn't try to make it better.

[CapeCodMermaid, RN]

It sounds obvious but if you chart you notified the MD about something, chart his response even if he didn't want to do anything. "MD notified that resident X's BUN was 70. MD declined any further treatment/new orders at this time." Or "Resident with wheezes, crackles,pitting edema. Requested CXR, MD declined at this time."

AND, if the families say something good, I ALWAYS put that in the note. "Daughter stated her mom hasn't looked this good in years."

As an aside, writing that you notified the supervisor of something does not end your obligation to deal with it. And, please, if you chart that you notified them.....NOTIFY them. I can't tell you the number of times I've picked up a chart to see "DNS notified" when no one had called me.