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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?
Pt tol well is a vague statement. I was taught to write what we observe to show they tolerated something well. Ex: Pt tol TF without emesis or s&s of aspiration. Pt tol neb tx aeb increased o2 sat of 98%. Lungs CTA bilat. Resp even, unlabored, 20.
Very good tip SDALPN! Definitely will apply this to my notes.
SDALPN
997 Posts
Pt tol well is a vague statement. I was taught to write what we observe to show they tolerated something well. Ex: Pt tol TF without emesis or s&s of aspiration. Pt tol neb tx aeb increased o2 sat of 98%. Lungs CTA bilat. Resp even, unlabored, 20.