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Willowjude

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  1. Proper Documentation

    Willowjude posted a topic in General Nursing
    Can you please give me your feedback about a debate we are having at work? I was doing a follow up note on an incident report for one of our patients that fell his injury was on his right eye and yet this other nurse was documenting his injury being on his left. The nurse responded that she was always taught to chart someone's injury whether it be on the left or right by how she is looking at the patient. So looking at the patient face to face his injury is on her left( his right in reality). So she's documenting the injury is on his left! Please tell me if I have been doing this wrong for the last 13 years. Reply

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