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?
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...
For real...
These are things you should not chart.
or :beer: (like drink myself to oblivion) It's a toss up as to which is the better response. Maybe both!
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
i've worked with a few people whose notes, if not professional, are great reading. the one about the alaris pump, for example.
or: "called dr. butcher because patient's femoral artery continues to pump blood into his retroperitoneal space, which would not have happened if the idiot hadn't insisted upon taking him to the cath lab while on a heparin drip." (or something to that effect.)
"attempted to remove central line prior to discharging patient, but patient ran off before it could be pulled. caught up with patient in the elevator, and he picked this writer up by the shirt and slammed her into elevator wall, stating he needed the central line to inject drugs because he'd already blown all the veins he could reach."
Specializes in Gerontology, Med surg, Home Health.
"Attempted to remove central line prior to discharging patient, but patient ran off before it could be pulled. Caught up with patient in the elevator, and he picked this writer up by the shirt and slammed her into elevator wall, stating he needed the central line to inject drugs because he'd already blown all the veins he could reach."
I had to explain to corporate once why I denied a guy with a PICC line. It seems he was taking his po meds in the hospital, crushing them and injecting them into his PICC line. Hmmmm...where do you suppose he got a syringe?
Nascar nurse, ASN, RN
2,218 Posts