Funniest or worst PDN notes.

[KATRN78]

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?

[Teacup Pom]

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.

That is funny!

[NottaSpringChik, BSN, RN]

Our agency switched to EMR last month. It is GREAT! Really helps out with the charting. In my opinion it helps with accuracy, is much more concise, less time consuming. Really appreciate it. Easy to use also. Everyone loves it.

[Elle23]

Our agency switched to EMR last month. It is GREAT! Really helps out with the charting. In my opinion it helps with accuracy is much more concise, less time consuming. Really appreciate it. Easy to use also. Everyone loves it.[/quote']

Noooo!!!!! I love paper charting!

I guess it's only a matter of time before all agencies make the switch, but until then, I'm clinging to the paper with all I've got!!

[Not_A_Hat_Person, RN]

Noooo!!!!! I love paper charting!

I guess it's only a matter of time before all agencies make the switch, but until then, I'm clinging to the paper with all I've got!!

My agency does everything on paper, and I hate it. I can't wait for the day we finally go paperless.

[BuckyBadgerRN, ASN, RN]

I'll write notes like "transferred to crib, X content, playing with 'Betsy'" which is an interactive stuffed toy she has. Betsy seems to make it into everyone's notes, LOL

[BuckyBadgerRN, ASN, RN]

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....

Hmm, not sure I like that at all. I change my client diaper. Don't think its billable, but if I don't write it, I didn't do it and any review of notes would make is seem like she was in the same diaper during my whole shift. Not sure that refilling her Joey bag is a billable procedure, but again, if you don't write it it didn't happen and I'm pretty sure they'd frown on me not providing her nutrition...

[BuckyBadgerRN, ASN, RN]

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?

I'll use "appears tired" when she's rubbing eyes, etc. She's unable to speak and say "hey! put me to bed, I'm tired!"

[BuckyBadgerRN, ASN, RN]

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.

So is my navel piercing, but it has healed and no pathogens are allowed to enter....

[Elle23]

Hmm, not sure I like that at all. I change my client diaper. Don't think its billable, but if I don't write it, I didn't do it and any review of notes would make is seem like she was in the same diaper during my whole shift. Not sure that refilling her Joey bag is a billable procedure, but again, if you don't write it it didn't happen and I'm pretty sure they'd frown on me not providing her nutrition...

I don't document in the nurses notes every time I change a diaper. I figure that's a given when I chart urine and stool in the I&O.

[SDALPN]

I don't document in the nurses notes every time I change a diaper. I figure that's a given when I chart urine and stool in the I&O.

In my state when they review the notes to decide on hours, they look at every skill performed. They don't use the flow sheets. If they don't see that you have done a certain number of tasks and a certain number of skilled nursing tasks, they will decrease the hours for the pt. This harms the pt who needs the hours and has an effect in your wallet too. The reviewer for the state will be asking your agency why you didn't report a pt that didn't void all shift.

[CT Pixie, BSN, RN]

I'll use "appears tired" when she's rubbing eyes, etc. She's unable to speak and say "hey! put me to bed, I'm tired!"

We were taught not to use appears or seems also. We were taught to write what exactly causes us to think this. IE: Pt appears tired vs pt rubbing eyes, yawning, heavy eyes blah blah blah.

[NottaSpringChik, BSN, RN]

I don't document in the nurses notes every time I change a diaper. I figure that's a given when I chart urine and stool in the I&O.

The EMR my agency has does not have any selectable item for a change of a brief either. We just document I & O, with source (diaper), which as you say, is a given that you changed it. When I had to write the Progress Notes out by hand I used to write a lot of things in them that apparently weren't really necessary. We can still write "general notes" too, but I make it a goal to use specific tabs with the selectable items as much as possible (respiratory, integumentary, muscular-skeletal, etc). We still have to write out in all the comment sections "patient tolerated well " or applicable phrase. Wish they would have put a selectable item "Patient tolerated well." Seems like if it was so important they would have had that box to select..... and if patient didn't tolerate well you could then write a note about that.