Can you chart too much?

[Herr_Krankenpfleger]

We had an incident a few months ago where a resident groped another resident. I did all of the typical nursing interventions, including separating the residents and contacting psych and the responsible party. I also made sure I documented exactly where happened in the medical record. Therein lies the problem.

Recently I was called into the DON's office where I was told be more vague about the incident. She stated i should use the term "inappropriate behaviour" instead of stating what happened. I told her that I stand behind my charting because I felt it was my duty as a nurse to make sure I chart accurately as possible. I also do so, because it leaves me a record of what is going on, just incase i have to defend myself. But management is adamant that I be more vague when I leave my notes because they want to make state look problems, instead of handing "it to them on a silver platter"

so my question to you all is...

Is this common nursing practice. I have always been told to be very descriptive when charting and many of my other managers have always told me that I chart really well?

[emmanewgrad]

You r right in documenting as you do, the right way.

[caliotter3]

I have heard it both ways. Usually you will get feedback to make things 'vague' if it is about an incident. I think you have to have an idea of where you stand in the scheme of things when you are thinking about slanting your charting one way or another. I would just chart it as I see it, instead of worrying about what I should or should not include or leave out.

[Mom2boysRN]

I'm aware of situations where a nurse was met with the same sort of feeback in a case such as yours. The nurse refused to change her wording, but it was "corrected" to managements liking in the computer system. I have no first hand knowledge of the situation I only know what the person directly involved told me.

[tyvin, BSN, RN]

This happens quite often. Don't want to have any red flags for inspectors to investigate. Didn't you also make out an incident report? If not you should have.

Management is always trying to sweep inappropriate sexual behaviour under the rug. I've seen pages of documentation gone missing, nurses notes amended by management, etc... I would hope that if a patient's well being was in danger from a sexual predator that it would be addressed accordingly.

Sadly the higher ups are thinking more of their reputation then the victims of such assaults.

[nurseprnRN, BSN, RN]

i review charts for a living and i can tell you, folks like me can smell bs a mile away, and i'm not talking "bachelor of science,":d. also, what tends to happen is the first chartings look pretty complete, then later ones get vaguer and vaguer as the a** covering begins. all reports are discoverable, no matter what they tell you about not mentioning incident reports. facilities or their corporate offices are required to keep reports related to qa, and part of qa is keeping a safe environment, and part of that is protecting old birds in their beds.

never, never use vague words. say exactly what happened and what you did. if the victim said, "he came into my room and pulled down my covers and felt me down there," then use exactly those words. "called into room 210, observed mr. smith standing next to ms. jones' bedside. ms jones stated, 'he came into my room and pulled down my covers and felt me down there.' walked mr. smith back to his room without difficulty, and asked cna to sit with him. don mary roberts rn called ms. jones's family member jane jones to inform her. ms. roberts informs she stated she would come right away."

do not say, "a resident reported that another resident did an inappropriate act." for one thing, by the time this ever comes to trial (if it does), ms. jones could be dead or more demented so she can't testify or even be deposed. another possibility is that the "he" could have spent the intervening years molesting other poor old birds.

[systoly]

I think I'd be looking for a new job and carrying a dictaphone in the meantime.

viel Glueck Herr Krankenpleger

[merlee]

Wow. I agree with the idea to chart exactly what you saw or what was reported. No opinions, just the facts.

It's your license, and the safety of the patients that count here.

Ask the DON if she wants her mother groped....

[CapeCodMermaid, RN]

[quote=tyvin;5895045

Management is always trying to sweep inappropriate sexual behaviour under the rug. I've seen pages of documentation gone missing, nurses notes amended by management, etc... I would hope that if a patient's well being was in danger from a sexual predator that it would be addressed

If I had a nickel every time someone on here made a blanket statement about management, I could retire to the South of France...or Cape Cod. My reputation as the DNS is tied into the facility. The DPH knows things happen...people fall, old people grope one another. What counts is how the facility deals with the incident. I investigate every allegation or hint of sexual misconduct. I report such things to the DPH. I urge the nurses in my facility to document in detail.

Not every person who touches another resident is a sexual predator. Most of the time they are just demented people who don't have any malicious intent.

[MrWarmHearted]

In an assisted living facility that i worked at in the past, we provide detailed descriptions in a separate incident report as opposed to their chart. perhaps that was what your DON was referring to

[noahsmama]

In an assisted living facility that i worked at in the past, we provide detailed descriptions in a separate incident report as opposed to their chart. perhaps that was what your DON was referring to

Yes, that was the practice at the peds hospital I used to work at too.

[Amanda.RN]

I would leave the detailed description of the situation for the incident report and keep it vague in the medical record, like "Ms. Smith reported inappropriate behavior by another resident. Incident report completed; Manager So&So informed."

When in doubt, it never hurts to contact your Risk Management department for instructions.