not documented, not done. what does this mean? - page 3
i am looking for a respnce to the statment 'Not documented, not done." Was this taught to you in nuring school, in clinical practice or it is a part of your policy manual, or all three?... Read More
Jun 22, '02Occupation: RN, CMSRN employed in a 600 bed Acute Care/Trauma Facility and CNA Instructor for a local Community College Joined: Mar '02; Posts: 459; Likes: 62Charting what we as nurses do for our patients is critical. Thankfully, flowsheets, MARs and the like make much of it easy with just a simple initial. Charting specific conversations and observations in Progress Notes or Computer Charting is vital to... as many others here have stated: CYA.
Be careful HOW you choose your wording. We had a patient who experienced oversedation with a morphine PCA. The nurse attempted to awaken the patient before administering narcan. Her documentation of the event, however, did not read very well... "Patient appeared lethargic, unable to awaken. Pt shaken without response. Sternal rub, with little response. Slapped patient across the face to try and awaken without much effect...." SLAPPED PATIENT ACROSS THE FACE?!?!?!?!
Let's just say this nurse had a long, DETAILED discussion with our Supervisor, following this little piece of documentation. Believe me, she's much more careful with how she phrases her comments now.
Jun 23, '02Occupation: Nurse Joined: Jun '02; Posts: 651; Likes: 3In Australia the Govt subsidises health care. So we have to document EVERYTHING, from technical nursing procedures to daily activities like T.V., listened to music, attended concerts but especially encouragement to attened to themselves, like choosing what to wear, washing thier own hands and faces etc. Mobility, chair, w/frame, hoist or stand and pivot etc. If it's not done we loose money and nursing hours. LOL!! Even visitors how many and duration of visit!! Money is a big incentive to get the paperwork done!! Plus we have the added benifit that the residents family and doctor have to be a part of the group formulating the nursing care plan so no-one can say that they didn't know what was going on.