Never chart this

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Specializes in ER.

Was just doing (yet another) mandatory education bit. Just had to share. Thankfully I did this, otherwise I might have charted these very things, since I never went to nursing school and like to shoot off my mouth on a legally binding document... ;)

•This patient is drunk.

•This patient is looney-tunes.

•This patient is a pervert.

•This patient is nasty.

•This patient smells like he has never taken a bath in his life.

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That is funny, but it makes me wonder what the heck happened at your facility that caused them to make this education mandatory.

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In those exact words, I can understand ...but surely you're allowed to imply???

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In those exact words, I can understand ...but surely you're allowed to imply???

Yeah, I agree but you could state facts.

Patient came into ER with foul odor, feces under nails, confused about person, place, time.

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Specializes in ER.
Yeah, I agree but you could state facts.

Patient came into ER with foul odor, feces under nails, confused about person, place, time.

You forgot that 'pt continues to expose his genitals to staff, even after being requested to stop. Appears to be masturbating'

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Specializes in retired LTC.

I worked with a nurse who would chart about "pt being NASTY". She really did use the word.

I did try to cue her in. This was years ago.

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You forgot that 'pt continues to expose his genitals to staff, even after being requested to stop. Appears to be masturbating'

Yeah, I got called away from the computer! :)

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Specializes in ICU, LTACH, Internal Medicine.
I worked with a nurse who would chart about "pt being NASTY". She really did use the word.

I did try to cue her in. This was years ago.

"Nasty" is an opinion.

"Patient is non-cooperative with treatment, demands increased doses of Dilaudid to be given as quick IV push, uses foul words and racial slur toward personnel, refuses to wear gown and attempts on walking around the unit completely naked" is factual description if the same, and is completely OK to chart. Just takes much more time to write down (we still use paper) :writing:

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Specializes in OB.

I work with an MD who has absolutely terrible documentation skills (actually kind of a terrible MD in general). Not only are her basic spelling and grammar atrocious (all her notes look like she was texting with mittens on or something) but she puts subjective comments in her notes all the time. I read a note of hers that literally stated "Patient is very Type A...needs to talk a lot." It seems like that's asking for a lot of trouble, but what do I know?

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Write this instead of that:

•This patient is drunk. ("only two beers, I swear!" )

•This patient is looney-tunes. (arrives with suitcase full of unused psych meds) *under personal possessions

•This patient is a pervert. (Invites you to see his "rare butterfly collection post discharge")

This patient is nasty. ( room malodorous like decayed road kill)-for some mysterious reason???

•This patient smells like he has never taken a bath in his life. (same as above)

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The chief attending at our small hospital charted that a patient had "a phlegmatic personality." Some definitions of phlegmatic don't seem to bad, but I'm sure the doctor meant sluggish, apathetic, etc.

One of those things I remember that happened over 30 years ago....wish I could remember where I put my tickets for The Lion King?

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The infamous "Pus*y" discharge from a wound, should be included in every "do not chart" discussion!

I had a 1:1 sitter chart "patient was acting a fool, RN knows"

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