I am doomed.

[Guest219794]

Often reading threads on here leads me to Google searches, and a bit of online research/reading. I just landed on this site, and came across this.

All in all an interesting read. But, I think I better up my insurance, and do something to protect my ass(ets). Apparently, my charting is not up to snuff.

25 LEGAL DOs AND DON'Ts OF NURSING DOCUMENTATION

1. "If you did not write it down, you did not do it. If you did not do it, youwere negligent." You need not just to chart what you did but how youdid it. Otherwise, how will you testify years later, with no actual recollection of the patient in question, that you did it right? For example:"ketorolac 20 mg IM" versus "The appropriate injection site in the gluteal muscle was located by reference to the patient's iliac crest. Then theinjection was administered into the muscle tissue using a pre-filled 30 mgsyringe with a 1 ¾ inch 18 gauge needle, after having attempted unsuccessfully to aspirate blood upon insertion of the needle. No complains of numbness or tingling in the lower extremity. 10 mg of the medication was wasted." What if the patient sues five years later claiming a sciatic nerve injury from your injection technique - which of those two progress notes do you want to have with you on the witness stand? The first one gives you no positive basis to testify that you did the injection correctly, and it is basically a toss-up whether or not you will be found liable.

[psu_213, BSN, RN]

You refer to your 'gloved hand.'

Come to think of it, I did forget to check the expiration date on the gloves.

[blondy2061h, MSN, RN]

I remember an exercise in a middle school class I took. The teacher was trying to teach us about technical writing and how detailed it needs to be. He brought in items to make peanut butter and jelly sandwiches and asked us to take turns telling him how to make the sandwiches, pretending he had never made one before. We all thought it would be easy until we tried and told him things like, "Spread peanut butter on the bread" and be smeared peanut butter over the entire wrapped loaf of bread. Hilarity ensued as we saw just how detailed you can be with instructions for even the simplest of things.

But do I want to apply that level of detail to my charting? Let's say I'm giving a dose of IV Zosyn due at noon. Do I want to chart about checking allergies, checking recent lab data, obtaining the dose from the fridge, letting it come to room temperature for an hour, logging on a computer, checking the mar, checking IV compatibilities, washing my hands, assessing IV patency, spiking the bag, programing the pump, double checking my programming, checking roller clamps, watching it drip, washing my hands again when I leave the room, reassessing the IV site and that the dose is complete after it's supposed to be done...etc. Every 6 hours for Zosyn and then for every other med.

You could write 3 paragraphs about every med. When I worked BMT it wasn't uncommon to give one patient 50 meds a day. And you know you're not going to type that out every time- you're going to copy and paste. So if you're just copying and pasting...at what point is it meaningless?

Then, nurse that follows me wants to know if the patient had any nausea complaints or unique issues or what not. So they try and go through my narrative notes to find that. Instead they're greeted by pages of narratives about hand washing and IV patency and scanning meds. That greatly diminishes the usefulness of your charting.

We complain about no one reading out charting. No one will ever read our charting if we chart a novel about everything we do. In fact, I suspect this post is too long for most to read.

[CelticGoddess, BSN, RN]

Does anyone know if we need to document the ambient temperature of the room? And the where the sun is in the sky? I mean, they are saying document nearly everything else but the patients underwear size!

[Meriwhen, ASN, BSN, MSN, RN]

This brings back nightmares of my student nurse days!

In the example above, I would most certainly go with the first entry, as long as it also included the injection site. (And no, I surely would not describe HOW I ascertained that I had correctly located the site.

Oh, the memories!

I would have done a hybrid of the two: not as bare-bones as #1, not as overly dramatic as #2. I'd take #1 and add injection site, time of injection, how the injection was tolerated and the patient's status shortly after (no complaints or c/o pain, numbness, etc). Maybe or maybe not add the gauge.

[BlinkyPinky]

This brings back nightmares of my student nurse days!

In the example above, I would most certainly go with the first entry, as long as it also included the injection site. (And no, I surely would not describe HOW I ascertained that I had correctly located the site.

Oh, the memories!

Oh my gosh; is your avatar picture YOUR 🐱cat?!?!

He\_she is ADORABLE!

[gemmi999]

I literally click a few boxes and hope I remember if I did it in the right or left deltoid, etc. I'm horrible at remembering left vs right being inverted for pt's.

[Kitiger, RN]

What if the pt comes to the ED in a few days and says "the nurse who gave me this IM injection caused this infection on my leg." Heaven forbid you didn't chart--"the area was swabbed with alcohol. Before swabbing I checked to make sure that the alcohol pad was not expired. I also went online and looked up the lot number to be certain that the supplier did not issue a recall on this batch. I allowed the alcohol do dry completely. I then removed the cap from the needle. I had previously checked, and the expiration date on the needle was 02/2024. I was certain to make sure I did not touch the needle with my gloved hand. In addition, I made sure that the exam room door was shut so that there was no abnormal air flow into the room which may have contaminated the needle. To be certain, I called EVS first to shut of the vent to the room to further prevent any risk for infection by pathogens that might be introduced into the room by this route."

After that you can move on to an IV insertion in a different room. That should only take 90 min or so to chart....

PSU, I think those pencil-pushers who sit behind a desk would probably approve your charting.

I get so tired of being required to double & triple chart, or being required to use certain words every time I chart. Sometimes, the people who sit behind a desk have too much power and too little knowledge.

Anytime they want to add one more "little" detail to our charting, they should be required to follow a nurse all day, while doing that nurse's charting (separate from the legal record, of course).

[bgxyrnf, MSN, RN]

You refer to your 'gloved hand.'

Come to think of it, I did forget to check the expiration date on the gloves.

And nowhere do I see it documented that you examined the glove to ensure that it was intact.

[Have Nurse, ADN, RN]

Does anyone know if we need to document the ambient temperature of the room? And the where the sun is in the sky? I mean, they are saying document nearly everything else but the patients underwear size!

I can't stop laughing....!!!!!

[PPediRN]

What if the pt comes to the ED in a few days and says "the nurse who gave me this IM injection caused this infection on my leg." Heaven forbid you didn't chart--"the area was swabbed with alcohol. Before swabbing I checked to make sure that the alcohol pad was not expired. I also went online and looked up the lot number to be certain that the supplier did not issue a recall on this batch. I allowed the alcohol do dry completely. I then removed the cap from the needle. I had previously checked, and the expiration date on the needle was 02/2024. I was certain to make sure I did not touch the needle with my gloved hand. In addition, I made sure that the exam room door was shut so that there was no abnormal air flow into the room which may have contaminated the needle. To be certain, I called EVS first to shut of the vent to the room to further prevent any risk for infection by pathogens that might be introduced into the room by this route."

After that you can move on to an IV insertion in a different room. That should only take 90 min or so to chart....

Thanks for the good laugh.

[JadedCPN, BSN, RN]

I was going to be funny with a very detailed reply but then I realized I can't even pretend to chart that detail oriented without forgetting a bunch of things...I'm really doomed!

[ComeTogether, LPN]

This charting method is a sure fire way to get yourself into trouble by saying too much.