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?
Do not chart conclusions, assumptions or hearsay (kinda like in court). Do chart facts. What You saw, what You heard, what You smelled, etc. Never chart "pt. fell" (most of the time nobody saw it anyway), never chart "found pt on floor" (the "found" implies the pt was lost). Do think about attending a seminar on charting (preferably the speaker is a nurse-lawyer)
The dumbest thing I was taught not to chart was ie: Client slept for approx 6 hours. Or had a restful night ect. As we were lectured, how do we know a patient is 'really' asleep. Have always disagreed with this. I guess because to me if a person is snoring their head off they're definately asleep --.--.
But anyway onto what I was taught to actually do XD
I was taught to only write Client, never patient due to the power imbalance of the word.
Hm... Basics were no unaccepted shortforms, no using firstperson in charting, to use quoting or description over saying an individuals mood or pain.
To use either the SOAP method, PIE method or charting in exception.
For me however I was taught to always use Dr and Nurse last names and 'always' to write in if a PRIME was done (incident report) if any harm or distress occured, otherwise if a report over say a documentation error or a no harm incident it didn't need to be charted.
Always chart objective not subjective information. If a resident is cursing write what was said. I hate to pick up a chart and read "inappropriate behavior." What does that mean? Moral values play into what someone thinks is inappropriate. Be specific.
Specializes in Gerontology, Med surg, Home Health.
Never write "Incident report done". Incident reports are INTERNAL documents which can not be subpoenaed. If you mention one in your note, however, it's fair game.
Never write "Incident report done". Incident reports are INTERNAL documents which can not be subpoenaed. If you mention one in your note, however, it's fair game.
I'm just interested, wouldn't it be better for the court to get a hold of the incident report? Well to help back you up as a nurse? My facilities system is obviously very different as we're encouraged to chart we've gone filled out a report and also pushed things along to the hierachy.
I'm in Australia, a public system so I understand laws are very different across countries. I'm just curious over the rationale, does it protect you better to not have the court have access to the report? Well on your side of the world.
Specializes in Gerontology, Med surg, Home Health.
Things are very different in the States where we get sued for all sorts of things. An incident report would only give more evidence that something 'bad' happened. Everyone seems to expect a perfect outcome to everything.....families who never visit 89 year old grandma want to sue if grandma has a fall. Ridiculous.
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.
You should always document a person's name if they report something to you or do something for your patient. I was just involved in a suit for my hospital where something was documented and all it said was nurse assistant and it was a mess since they couldn't figure out who this NA was and we couldn't have her testify. But I also work in a field that a chart can be over 18 years old by time it goes to court, but it is still a good practice to follow.
Specializes in Gerontology, Med surg, Home Health.
I identify the other nurses by name in my notes:" Had family meeting. Daughter Janet Smith, RN Pat Wall, SW Jane Johnson, and administrator Mike Lamp present for the meeting." That practice makes it easier to go back and track who was actually at the meeting in case the crazy family member says something crazy. We had one family member claim there were '5 women in the room and they tortured me for an hour'. I had documented the meeting and it was easy to find those people and determine what actually had happened.
Things are very different in the States where we get sued for all sorts of things. An incident report would only give more evidence that something 'bad' happened. Everyone seems to expect a perfect outcome to everything.....families who never visit 89 year old grandma want to sue if grandma has a fall. Ridiculous.
Wow that sounds awful --.-- I can totally see why you wouldn't want to write that you've done an incident report then.
Amazing how systems and cultures can differ huh. To me that's completely going over the top like a psycho family member you meet once in a blue moon.
Specializes in Gerontology, Med surg, Home Health.
Wow that sounds awful --.-- I can totally see why you wouldn't want to write that you've done an incident report then.
Amazing how systems and cultures can differ huh. To me that's completely going over the top like a psycho family member you meet once in a blue moon.
Trouble is, we meet psycho families EVERY day. And there are plenty of ads on television by attorneys urging families to sue the nursing home for a fall or a pressure ulcer or an 'unexpected death.' Frankly, if you don't expect to die when you're 97, when is it expected?
Trouble is, we meet psycho families EVERY day. And there are plenty of ads on television by attorneys urging families to sue the nursing home for a fall or a pressure ulcer or an 'unexpected death.' Frankly, if you don't expect to die when you're 97, when is it expected?
Sheesh they have 'ads' advising people to sue places?? What is this breed distrust into the community?
The attornys should be ashamed of themselves, well in my opinion. I'm not opting for anyone to suffer, but encouraging irrational behaviour over logic and consideration to me is disgraceful. The families have to go through someone passing away. It's painful enough, it's better to accept it gradually over fighting for a life that no doubt ended as it will for all of us. It prolongs the families suffering ...that and drags the poor carers and nurses into it as well.
Maybe that's the difference? And why we're encouraged to chart our Primes, because we certainly don't have advertising like that, being sued is one of our least concerns. We're taught if we follow protocol we are safe.
We were always told to chart what we see, feel, hear, smell. Never to chart anything about an incident report. And, to chart in a form that is understandable and clear. I once charted on a home health patient that her abdominal wound smelled like a sewer and that I notified the doctor of this - my supervisor saw nothing wrong with it and recommended that I also fax the note to the MD, which I did. I got lots of action for the patient on this note.
systoly
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Do not chart conclusions, assumptions or hearsay (kinda like in court). Do chart facts. What You saw, what You heard, what You smelled, etc. Never chart "pt. fell" (most of the time nobody saw it anyway), never chart "found pt on floor" (the "found" implies the pt was lost). Do think about attending a seminar on charting (preferably the speaker is a nurse-lawyer)