Medical/Legal Charting

[dotherightthing]

If upon discovering that a patient was cut accidentally, with scissors while discontinuing an IV for instance and you note an open area, without bleeding or drainage, do you chart it as a laceration? Or should you describe what you found?

[TazziRN, RN]

If you did the cutting, chart what happened: "(size) laceration sustained to (location) inadvertently while cutting (item) with bandage scissors." Include your intervention. Make sure you fill out an incident report.

If you found the wound, chart what you see and what the pt said happened.

[ceecel.dee, MSN, RN]

Oh dear...this is not easy. If you stumble upon anything like this, I think it must be reported to the charge nurse. Hopefully she will deduce the same thing you did...if not, the topic must be addressed. I think the charting includes objective data only...no speculation about what anyone "thinks" happened. If you actually witnessed the "breech", ...only then can you chart it objectivly. This type of thing is typically addressed via an incident report and not in the charting.

[traumaRUs, MSN, APRN]

You state what happened and go from there:

"DC'd SL - noted 0.5cm abrasion under tape." I would also make out an incident report and report this to the charge nurse as well as the unit manager.

[Nursebarebari]

Not legal, next time, say no and that you will add whatever is missing in the note as a late entry.

Learn to protect your license.