Quote from SisterJ392000
After 18 rears as a LPN I had to relearn charting protocol when I went to RN school. I still wanted to write "Appears to be sleeping" now a no-no.
I had a disagreement with a charge nurse recently; I was going over student notes and found "pt seemed tired" or "appeared tired" or something like that, and I commented on it. She told me that the student was right, etc etc, it was objective data....this was NOT correct IMO, not according to everything I had learned (and much more recently than she; perhaps when SHE was in school, where she went to school, it was different). At any rate, it IS a no-no to chart what they "appeared" to be; chart what they ARE!
One other I can remember is don't chart side rails up x 4, that is considered restraints! It was news to me but apparantly you can only chart up to 3 side rails up at a time!
Actually, this will vary depending on where you are, and the facility that you're in, and their policies too. I was in one hospital where x4 was a restraint, but the one I'm in now does it routinely, NOT a restraint. And it's not like anyone is messing up, it's a hospital-wide policy that has been seen by TPTB.
I had no clue before going to school what the big deal about charting was, LOL...figured you just jotted down their vitals and what the doc said, right? ROFL...