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Funniest or worst PDN notes.

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by KATRN78 KATRN78 (Member) Member

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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?

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SDALPN specializes in Peds(PICU, NICU float), PDN, ICU.

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Sometimes nurses write playing with toys to indicate that the child is ok at the moment. The law requires a note at least every 2 hours and there may be nothing else to document. And with the gtube, I typically write "site without redness, odor, or drainage". But overall assessment would still say w/d/i.

I'm more concerned when I read a nurses notes that say "uncircumcised testicles". Yep, saw that a few months ago!

Or the nurse that wrote she "sunctioned"

Today with the new month, I saw where the nurse who put the times on the MAR incorrectly. She write them as 0002 instead of 0200...0008 instead of 0800.

Also read a nurses notes that stated "pt unsecured in w/c fell out of w/c on to floor"....that's asking for trouble.

But to note the kid is playing tells the reader what is going on. Better than saying the pt is on the floor and not saying what they are doing on the floor. If you go 2hrs without writing anything, it could be assumed that the kid just sat on the floor for 2 hours.

I'm sure I can think of more notes I've seen that are bad. Poor grammar also looks bad. Some nurses make me wonder how they passed their English class!

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SDALPN specializes in Peds(PICU, NICU float), PDN, ICU.

997 Posts; 16,260 Profile Views

Oh, the title should say "worst", not "worse". ;-)

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roser13 has 17 years experience as a ASN, RN and specializes in Med/Surg, Ortho, ASC.

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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." ?

 

 

For the same reason that I would chart that my patient is "resting with eyes closed, regular, even breathing, in no apparent distress," or was observed "autonomously toileting self." To show that (a) I am paying attention to my patient regularly, and (b) all is well.

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meanmaryjean has 40 years experience as a DNP, RN and specializes in NICU, ICU, PICU, Academia.

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Not gonna lie- I once charted a score-by-score account of the 1987 SuperBowl I watched with my PDN patient. I worked in Chicago at the time and it was the year of da' Bears and the SuperBowl Shuffle- and my C1-C2 quad teen-aged boy patient and I had a blast. I let him tell me what to write. Every single entry started 'Patient states...'

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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I chart skin grossly intact. In reading the 485 goals skin intact is related to breakdown and open wounds. The GT is a healed stoma/tract

Playing with toys is indicative of global mental status and alertness as well as level of functioning. I don't think it's an odd or "worst" thing to chart. A five paragraph dissertation on all of the PT's intervention that the PDN is not involved in is a bit much, especially since PT creates their own notes. Worse when the same nurse charts 2-3 lines of narrative for a 12 hour shift Kind of hard to justify the need for skilled nursing during an insurance audit. Granted we don't need the specifics of which tv shows are watched or a list of books read...but the attention span in a pediatric client is definitely relevant.

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229 Posts; 5,169 Profile Views

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

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roser13 has 17 years experience as a ASN, RN and specializes in Med/Surg, Ortho, ASC.

6,504 Posts; 50,978 Profile Views

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

Other than adding a few more details as to how exactly (what skills are being utilized), the child is playing, why do you think that the chart note needs to be more professional?

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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Do you mean like:

Client interacting with siblings, initiating play with age-appropriate sensory toys while in supported seated position. Reaching for preferred play objects. No s/s discomfort or distress noted. Respirations equal & unlabored.

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roser13 has 17 years experience as a ASN, RN and specializes in Med/Surg, Ortho, ASC.

6,504 Posts; 50,978 Profile Views

At any rate, your examples are far from the funniest or worse [sic] chart notes that we've seen.

I'm curious - are you in a position of somehow evaluating documentation/chart notes?

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229 Posts; 5,169 Profile Views

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....

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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Why would you not document relevant observations? If you are caring for a developmentally disabled child with neurological, attention and/or endurance issues, why would the fact that the child has sufficient cognition to initiate play, a desire for age/developmentally appropriate interactions and activities, and even sufficient motor development to participate in appropriate pay not be a relevant observation to document? If a child had cognitive and developmental delays that did not permit typical childhood play, but can now initiate reciprocal play or interaction, or develop fine/gross motor control to move a ball, or even increase attention span to developmental milestones to sit still to watch a tv show or listen to a book these are all relevant developmental milestones that should be documented to show that the skilled nursing care is therapeutic and not custodial care to justify continued coverage.

Perhaps watching TV, details such as what books were read or what shows are watched are not truly necessary. Not sure I'd willingly document that not only did I inappropriately have my cell phone out while working but also let the child laugh & play with my personal cell phone.

Developmental and cognitive observations are relevant when working with the medically complex pediatric population. Why would it not be considered skilled nursing to document such observations? Developmental and cognitive milestones are part of basic nursing education (whether practical or professional nursing) hence the required knowledge of Erickson's and Piaget and other developmental stages and coursework such as developmental psychology or human growth & development. Knowing what is normal physical, cognitive, and emotional development is critical when working in pediatrics. The skilled nursing expertise and knowledge is what differentiates the necessity of skilled nursing care vs. custodial care/babysitting.

I'd be more concerned about inaccurate documentation of progress to goals which can prove or disprove the need for continued skilled nursing care. If the goal is "client will receive adequate nutrition and hydration to support normal growth and development without s/s of reflux or intolerance" Progress should not be documented as the goal regurgitated "Client will receive adequate nutrition" or if the goal is "Client will be monitored for s/s of seizure activity and treated as outlined in the plan of care" should not be documented in the progress to goals as "client will be monitored for s/s of seizure activity".

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