Funniest or worst PDN notes.

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In my year of PDN I have read some terrible notes!

Why do nurses write things like "patient playing with ball on floor and watching tv. nurse read book to patient" or "patient played with nurses cell phone, laughing." ?

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

What strange notes have you seen?

"patient's dipper fell off in bed" ..... for weeks I wondered what a dipper was. One night as I was about to dose off it hit me. DIAPER!

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I used to work with a nurse that would chart in the narrative " incontinent care given for bladder" or "incontinent care given for bowel and bladder". I always found the phrasing a bit odd.

Why not just chart "diaper changed"? The rest is recorded in I&O.

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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.

I still consider non-intact skin to be an acute event requiring intervention and not a long-standing, healed GB.

A healed GB is baseline normal for these patients.

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Specializes in Complex pedi to LTC/SA & now a manager.

I still consider non-intact skin to be an acute event requiring intervention and not a long-standing, healed GB.

A healed GB is baseline normal for these patients.

This is what I was taught. Non-intact skin is an abnormality for the patient such as excoriation, wound, rash , or breakdown that requires intervention whereas a healed stoma is WNL/baseline. . It may be chronic breakdown such as a stage 2/3 ulceration post extended hospitalization or prolonged bed rest not necessarily acute but requires skilled nursing intervention/treatment. This is also the policy at both agencies that I work for (one national and one regional).

I know a nurse that did not understand the concept of regular vs irregular/constipated BMs. A routine/normal for patient formed BM would be charted as "changed regular BM diaper " whereas instead of charting a loose BM, watery stool or diarrhea would chart "changed irregular BM diaper". Sigh. No amount of explaining by the nurse educator made any difference in comprehension either.

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Specializes in Public Health, L&D, NICU.

Once watched a sleep deprived coworker make this note regarding a newborn: "Baby resting quietly in open tree." Baby's name had something to do with "tree", like Roundtree or Greentree, and the baby was resting quietly in an open crib. I pointed out her unique way of containing infants, and she quickly redid her note.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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....
Your employer wants you to chart only billable things....because that is all they care about.....what is billable.....they don't want any extraneous information because if it is documented too much that the child is well....then services could be decreased and they lose money.

However If....for whatever reason there is a lawsuit filed about the child in question you will be left vulnerable for if it wasn't charted is wasn't done and doesn't exist.

For example....lets say a child experiences a change in neuro status....when did this change occur? Was it sudden? how was the child acting prior to the event? Lets say....someone who came to visit the home....was playing with the child....you went to use the restroom and they shook the child....and left. It is the end of your shift...the baby seems off and doesn't focus as usual...it strikes you odd that this seemed to occur after the visitor left in a hurry...you chart nothing. The baby deteriorates on the next shift they look at the note to try to piece together the sequence of events....this baby has been shaken/abused......and they can't...they know only that you didn't document how the baby was and if that was normal behavior....for you documented no behavior at all......trust me your employer will not have your back and will toss you under the bus so quick and you are now fighting against criminal neglect, and to keep your license.

Skin can be intact with GT......just because there is a opening/insertion site doesn't mean that the skin is not intact. The insertion site is intact if there is no exudate, drainage, smell, open areas, redness and swelling. The skin in intact around the stoma site without signs of infection.

Each school has their own methodologies, but that doesn't mean they know what is best in the real world....... it is usually best to have some post graduate CEU's in documentation that is about liability and accuracy. Documentation failures/inaccuracies remain one of the largest litigation points and liability to a nurses license. It is very important that ALL nurses carry .....for you company will not have your back. It diesn't matter what they tools you to do....as a reasonable and prudent nurse you should "know better".

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Specializes in Peds(PICU, NICU float), PDN, ICU.
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

Resting with eyes closed is because we aren't doing tests at the moment that prove the pt is sleeping. You can also add that they are easily aroused from resting with with eyes closed if that helps. In court, you could be asked to prove how you knew the pt was sleeping. When you can't back up the statement, you can lose credibility. Hope that helps :-)

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Specializes in Peds(PICU, NICU float), PDN, ICU.

The OP asked how documenting that the child is playing could be written more professionally. I also document that I'm reinforcing therapies as directed by therapists. Or that I'm encouraging developmental play. It sounds better and like we are more involved in their care. You can also write that the pt is watching TV and all needs/requests are met at this time.

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Specializes in Complex pedi to LTC/SA & now a manager.

Resting quietly, eyes closed respirations equal. & unlabored. No s/s discomfort, distress, or seizure activity observed.

Unless the patient is connected to a PSG machine you have no definitive way to confirm a patient is asleep (adult, child, globally delayed or neuro typical/neurologically intact).

I was taught this in school, at one agency, and also in a class taught by a nurse malpractice claims examiner.

Take it for what you want. If there is an issue or query you are the one responsible to explain your choice of words used to document your nursing narrative.

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Specializes in orthopedic/trauma, Informatics, diabetes.

My favorite (but not funny): "...client be chillin' in the bed". Client had passed on. Don't think they meant that the way it ended up, but a terrible pun.

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Specializes in Public Health, L&D, NICU.
My favorite (but not funny): "...client be chillin' in the bed". Client had passed on. Don't think they meant that the way it ended up, but a terrible pun.

My mouth is hanging open. What the??? Even without the death, that note is just all sorts of wrong.

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Specializes in Short Term/Skilled.

insead of "passy muir" nurse put a "u" where the "a" belongs......hehe she got teased about that one for a long time!!

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