Mic-Key g-tube documentation

[nurse4sale]

I have to do weekly balloon checks for 5cc sterile water on my pediatric patient. How is the best way to document this? I documented: Mic-Key g-tube 5cc balloon weekly check done, 5cc water in balloon. Child tolerated well.

Should I add, or delete anything in my documentation?

[KelRN215, BSN, RN]

I document "Mic-Key balloon checked, 5 mL clear fluid withdrawn and reinstilled."

[JustBeachyNurse, LPN]

Same here "MIC-KEY button balloon volume checked, 5mL clear water withdrawn and reinstilled/replaced" If a client requires patient status "Patient calm throughout check, NAD"

We are not permitted to use "cc", must always use "mL" in documentation. We are not permitted to use "tolerated well" as it is too ambiguous and can be interpreted any different ways

[NotReady4PrimeTime, RN]

I'd probably also include, "Mic-key remains in situ with gastric contents obtained post-procedure."

[nurse4sale]

Thank you so much, everyone. The info you've provided is a big help.

[KelRN215, BSN, RN]

We are not permitted to use "tolerated well" as it is too ambiguous and can be interpreted any different ways

I find this interesting, as I write "pt tolerated well" in my notes pretty much every day.

[JustBeachyNurse, LPN]

I find this interesting, as I write "pt tolerated well" in my notes pretty much every day.

It was flagged as too ambiguous by a few auditors. As there is no standard definition of "tolerated well" some of the insurance auditors questioned the need for intense skilled nursing. We are supposed to write "Patient tolerated without s/s of distress or agitation. Smiling post procedure...blah blah blah blah" or Patient tolerated with minimal agitation, crying. Easily consoled by parent yada yada yada" The current mantra is more specific details in charting can help justify the need for the current level of skilled nursing, which on the surface at least makes sense.