Charting on safety

Nurses General Nursing

Published

Specializes in Emergency, Telemetry, Transplant.

The other day I was relieving a nurse for lunch. After she gave me report, I opened the pt's chart and reviewed things. This nurse (who wants everyone to know that she is the superior nurse to everyone else on the unit) had charted "all safety measures implemented." In addition, she had not filled out the "check box" forms that are on the fall risk sections (check boxes for "bed in low position", "call light within reach," etc.). I'm presuming that she skipped this since she had previously charted that "all safety measures" were in effect.

Now, I don't know about other nurses, but my idea of "all" safety measures are different for (a) a 21 year old who is the ED for a broken finger, (b) a 91 year old with a H/O falls and a probable UTI, and © a 45 year old who is suicidal with a plan.

Am I just being silly about this or will this little "all safety measures implemented" do nothing to protect her if there is an issue with a pt and the :poop: hits the fan?

Up Vote Up Vote ×
Specializes in Trauma Surgical ICU.

I don't like vague statements like that.. If something should happen and it goes to court, a lawyer will have a field day with that statement. But that's just me. It's a shame we have to be so careful in our documentation.

Up Vote Up Vote ×
Specializes in Acute Care, Rehab, Palliative.

I agree. I make sure I check off which safety measures I put in place.If I check off "bed in low position" then the bed was put in that position. It helps jog my memory too.

Up Vote Up Vote ×
Specializes in Emergency, Telemetry, Transplant.
I don't like vague statements like that.. If something should happen and it goes to court, a lawyer will have a field day with that statement. But that's just me. It's a shame we have to be so careful in our documentation.

Another one that many nurses chart that I "like" is "comfort measures provided." Another nice little platitude that makes the person who did the charting feel better.

Up Vote Up Vote ×
Specializes in Trauma Surgical ICU.

"comfort measures provided" so what does that mean?? lol Is the person dying..

I just state foley care, skin care, turned, mouthcare etc completed.. No need to go into too much detail unless there is an "issue"..

Up Vote Up Vote ×
+ Add a Comment