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Funniest or worst PDN notes.

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by KATRN78 KATRN78 (Member) Member

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You are reading page 2 of Funniest or worst PDN notes.. If you want to start from the beginning Go to First Page.

nursel56 has 25+ years experience and specializes in Peds/outpatient FP,derm,allergy/private duty.

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My agency says that the only thing that should go into nursing notes are things that can be billed to insurance companies. In both school and in training (by my employer) we were urged to not document things like "playing, watching tv," etc....

We have flow sheets that document what the child (or adult) is doing every two hours. They seem to leave a very small area for the narrative, most likely by design. They like the language to be spare so you might say "watching TV" but some nurses write stuff like watching the Walt Disney classic Lion King made in . . . etc.

Some of the nurses squinch two lines into one line and write up the side of the form, ensuring that none of their extremely detailed documentation will be legible even before it gets to the third copy of our triplicate notes. Throw in handwriting, letter formation and spelling and it's really hard to see the value of notes like that.

The one thing we must do is do patient/parent teaching every shift and document it for insurance purposes.

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KelRN215 has 10 years experience as a BSN, RN and specializes in Pedi.

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What would be a more professional way to chart "the child is playing"?

What is unprofessional about stating that the child is playing if (s)he is, in fact, doing so? When I worked in the hospital (a large, nationally known pediatric hospital), we were expected to chart activity q 1-2 hrs. Playing was one of the options and is a perfectly appropriate thing to chart as far as activity goes.

I also don't consider skin to be "non-intact" just because a child has a G-tube or a central line. It's not a wound, it's a healed tract if it's a long standing tube.

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oh lets not forget nurse charting "skin dry, pink and intact" on a child with a G-tube. G-tube doesn't = intact

If simply having a hole in your body means your skin is not intact, we're all in trouble!

My patient has a GB and of course I chart the skin is intact. Non-intact skin to me is skin that is actively broken down, excoriated, bleeding, infected, etc.

My patient has the most beautiful looking GB site I have seen in all my years of nursing. Not an spot of drainage or even redness have I ever seen. It is truly a sight to behold!

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smartnurse1982 has 7 years experience.

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Somebody,please explain the "resting with eyes closed" thing.

Are you implying sleep?

Also,if a child isnt alert,but has a sleep/awake cycle,how can we truly chart "watching tv"?

I work with a little guy who,while it appears he is watching tv,he isnt.

He cant speak,follow with his eyes,no response,etc.

Global delays

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415 Posts; 5,161 Profile Views

Somebody,please explain the "resting with eyes closed" thing.

Are you implying sleep?

I think the point is not to assume the patient is sleeping. They could just be resting. ?

I always chart that my patient is sleeping. Not too many 8 month olds I know "rest with their eyes closed"!

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smartnurse1982 has 7 years experience.

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I was taught you dont use words like "appears" and "apparent" becuase it makes it seem like you are unsure of what is going on.

Is there anyone else that was taught that?

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sharpeimom has 20 years experience and specializes in ortho, hospice volunteer, psych,.

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We had at-home hospice care for my dying mother. Near the end, as the cancer migrated hither and yon, she did NOT want me near her, which meant an increased number of hospice aides. Sometimes, their notes were either unintentionally hilarious or kinda scary.

Pt. ate well and seemed to enjoy her meal. (She drank half a can of Ensure and ate a couple bites of yogurt.)

Pt. enjoyed visit from out-of-town niece. (Great, she DID enjoy herself very much with my cousin who visited in his priest's collar and vestments because he had come from doing a funeral.)

Pt. sat in her rocker and watched TV all afternoon. (Uh...excuse me. Mom's been unconscious and totally unresponsive, except to painful

stimuli, since Monday evening.)

Pt. seemed agitated. Given "a Ativan." Dosage? (Gee, I hope not, 'cause she's allergic to them.)

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smartnurse1982 has 7 years experience.

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One last question,i promise.

I wrote this question on the general forum,but i will ask again.

I have the same pt in my post above.

He is unreponsive. How can i write "No s/s of infection noted" if he can't talk and tell me his symptoms?

I usually write "No signs of infection noted".

Is that incorrect?

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415 Posts; 5,161 Profile Views

This is totally off topic, but I just realized you are sharpEImom and not sharpIEmom!

Maybe it's lack of sleep from my night shifts, but I could never figure out what sharpies and motherhood had in common!

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nursel56 has 25+ years experience and specializes in Peds/outpatient FP,derm,allergy/private duty.

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Elle I thought the same thing for longer than I care to admit. :wacky: Sharpiemom. Fondess for indelible felt-tipped pens. Hey, who am I to judge? lol My friend is very patient, and I don't get nurses writing down a subjective feeling like "enjoyed", either!

Smartnurse - I always chart to the diagnosis so I would not write "watching TV" even if he was looking in the general direction of the TV. Depending on what his baseline is for his diagnosis and condition I would chart how he responds to visual stimuli, if he tracks an object etc. It would be inaccurate to use that phrase, imo.

I just don't have the answer yet to "sleeping", "appears to be sleeping" and "eyes closed, respirations even, etc" but it sure would be nice to have some standardization there!

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229 Posts; 5,170 Profile Views

intact skin: Healthy skin in which there are no breaks, scrapes, cuts, or abnormal openings that allow pathogens to enter.

A G-Tube stoma is considered an abnormal opening.

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CaringGerinurse525 has 2 years experience.

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I always chart "Resting in bed with eyes closed, respirations even and unlabored..." I was taught in school to never chart patient/resident sleeping because I can not actually prove they are sleeping and not just resting. When charting I always ask myself "how would this hold up in court"? I can see a lawyer asking me "how did you know for sure they were sleeping"? Truth is I wouldn't because anyone can "play possum".

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