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?
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?
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.
Always know and follow your facility policy in terms of incident reports. I know it's drilled into our heads from day one to never mention an incident report in our notes but it's no longer an absolute rule.
In the last couple of years, in the Pacific NW, I did consulting work for 2 different SNF/LTC entities where it was not only policy to reference the incident report a copy of it went in the chart. These were not single or stand alone facilities, one was a Regional hospital affiliated group of facilities, the other a national chain.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
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.
good advice, but i fear it needs a bit of clarification:
if the patient is in pain, document it. but you must also document what you've done about it.
if the patient is a pain, don't document that.
if the patient is suicidal, it should be documented. so should your interventions be.
if the patient is making you suicidal, just come here and vent -- please don't put that in the chart.
if the patient has a new skin tear or decub, it must be documented . . . as should the notification of appropriate persons and the treatment.
if the patient has given you a skin tear, please fill out an employee injury form so that when you develop cellulitis from the rare bacteria usually found only in the orifice of farm animals that somehow happened to be under your patient's fingernails when he scratched you, the hideously expensive antibiotics can be paid for by your hospital.
if the patient has crackles to the top, is pale, diaphoretic and complaining of chest pain, you should definitely document it. but please document which doctor you notified, at what time, what orders you received and whether or not you've actually gotten around to carrying them out.
please document abnormal lab values and notify the appropriate provider. please do not call a provider to inform them of normal lab values at 3am. if you do happen to foolishly call a provider at 3am to tell him or her that the potassium is 4, please do not complain about (or report) the profanity you may be subjected to.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
i beleive we are not to use the word "agitated/agitation" other than that i dont know and am curious myself.
i think "agitated" is a fine word -- i use it a lot. but "confused" should be explained a bit. did he go to sleep at donkeybutt memorial clinic and wake up at the mayo clinic? perhaps he's entitled to be a bit "confused and disoriented." or is he attempting to converse with an alaris pump and incensed because "that uppity bastard won't talk to me."?
"inappropriate" is another term that ought to be explained a bit more fully. if he's making passes at all the pretty young nurses that's definitely inappropriate, but i'm thinking more along the lines of "inappropriate" as in trying to urinate in the waste basket or his roommate's bath basin. or picking nonexistant bugs out of thin air. or perhaps drinking from his urinal. (by the way, if you call the provider to inform them that their patient is drinking from the urinal, try very hard to refrain from laughing as you talk to them. some providers take a dim view of that sort of thing.)
Thank you for all of your responses!! This turned out to be a great thread! I'll also be sure to check out the JCAHO site. Someone suggested that I take a seminar on appropriate documentation -- that's a great idea, but my workplace has yet to offer one. I'll have to look around in my city.
Always know and follow your facility policy in terms of incident reports. I know it's drilled into our heads from day one to never mention an incident report in our notes but it's no longer an absolute rule.
In the last couple of years, in the Pacific NW, I did consulting work for 2 different SNF/LTC entities where it was not only policy to reference the incident report a copy of it went in the chart. These were not single or stand alone facilities, one was a Regional hospital affiliated group of facilities, the other a national chain.
Yes, my facility is one of those that have a policy to reference the incident report and a copy of the report goes into the chart. We are to use this form as our nurses note. I still can't wrap my head around this one and it has been a few years that we've had to do this. It is a corporate thing too.
A big never to chart is blame. I've seen it before...
"7-3 nurse did not give bp meds to resident. BP 160/90......."
A better way to chart.."Per resident am bp meds held due to nausea and vomitting..bp now 160/90. Call placed to MD......"
Very, very true. I have seen this before too. Charting is NOT about pinning blame onto others; it's about charting objective information and your nursing interventions on the patient!
I feel that if all nurses, doctors, interdisciplinary staff, etc could just remember WHO their priority/task is (ie, patient), things would go so much easier. Wishful thinking, of course.
good advice, but i fear it needs a bit of clarification:
if the patient is in pain, document it. but you must also document what you've done about it.
if the patient is a pain, don't document that.
if the patient is suicidal, it should be documented. so should your interventions be.
if the patient is making you suicidal, just come here and vent -- please don't put that in the chart.
if the patient has a new skin tear or decub, it must be documented . . . as should the notification of appropriate persons and the treatment.
if the patient has given you a skin tear, please fill out an employee injury form so that when you develop cellulitis from the rare bacteria usually found only in the orifice of farm animals that somehow happened to be under your patient's fingernails when he scratched you, the hideously expensive antibiotics can be paid for by your hospital.
if the patient has crackles to the top, is pale, diaphoretic and complaining of chest pain, you should definitely document it. but please document which doctor you notified, at what time, what orders you received and whether or not you've actually gotten around to carrying them out.
please document abnormal lab values and notify the appropriate provider. please do not call a provider to inform them of normal lab values at 3am. if you do happen to foolishly call a provider at 3am to tell him or her that the potassium is 4, please do not complain about (or report) the profanity you may be subjected to.
hope this clarifies things.
thanks for the chuckles!
another thing i know: no matter how "friendly" you are with your co-workers (nurses, aides, even the charge nurse), don't complain or talk about a difficult patient to them, either. you don't know how your words will be taken out of context and reported to a supervisor or don. whether we want to believe it or not, there's troublemakers on every unit. also, if you're on a floor like mine where family members are constantly around at any point in the day, it's also a good idea to keep your mouth shut. you don't know who's listening! an upset family member may file a complaint if they hear you talking about how obnoxious it was to give grandma betty her medicine this morning or how mr. y's poo always stinks so much.
knowing the employee injury protocol is a plus too from what i've found out from working on an alzheimer's/dementia unit.
This may vary by facility, but I've been told never to document "med xyz unavailable". You can circle your initials on the MAR and document "med xyz ordered from pharmacy" because it says that you're attempting to correct the situation. "Unavailable" implies that you, or the facility, is/are not providing what the person needs.
Specializes in LTC, ER, ICU, Psych, Med-surg...etc....
I have seen:
Resident eloped from the back exit door because the previous shift forgot to turn the alarm back on...
Medication was not available because the pharmacy didn't deliver it because the last three shifts did not order it...
Resident found on the floor beside the bed with a laceration to the forehead. Fall mat didn't save him because the CNA didn't put it down and didn't turn the alarm on...
Specializes in Gerontology, Med surg, Home Health.
I have seen:
Resident eloped from the back exit door because the previous shift forgot to turn the alarm back on...
Medication was not available because the pharmacy didn't deliver it because the last three shifts did not order it...
Resident found on the floor beside the bed with a laceration to the forehead. Fall mat didn't save him because the CNA didn't put it down and didn't turn the alarm on...
We are to use this form as our nurses note. I still can't wrap my head around this one and it has been a few years that we've had to do this. It is a corporate thing too.
JDZ344
837 Posts
Crazy world