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leslie :-D

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  1. leslie :-D's post in What To Chart After "pt. vomited" was marked as the answer   
    We never want to write notes that make the reader assume.
    The only exception I would take is to NOT write pt sleeping.
    Wouldn't that be an assumption as well?
    Rather, "pt laying supine with eyes closed. resps even and non-labored."
    elkpark, love your idea, about asking pt how s/he feels then writing response.
    It's unfortunate we have to be so guarded and meticulous w/our nsg notes, but we really do need to write as if a lawyer may be reading it someday.

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