Proper Documentation

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  • 88476aa05d63394d8ca9266372b2d6d7?s=96&d=http%3A%2F%2F0.gravatar.com%2Favatar%2Fad516503a11cd5ca435acc9bb6523536%3Fs%3D96&r=GCan 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.
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Specializes in Trauma, Orthopedics.

Um...no. why would you ever do that? Makes no sense at all.

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There is no debate. The patient's left eye is always going to be the patient's left eye.

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Specializes in Nephrology.

She just dont want to admit that she assessed the patient wrong.

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Specializes in NICU.
Anatomical position. First thing you learn in A&P. Was she asleep that day?
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Specializes in Palliative, Onc, Med-Surg, Home Hospice.

It's the right side of HIS body. It should be documented as the right side. Try pointing it out this way to her: If a surgeon is going to amputate the right foot for a non-healing ulcer, what food should he amputate? The patients right foot, or the left foot because it's on the surgeons right?

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Specializes in Emergency, ICU.

No, you haven't. Your colleague has been though 😬

Really? It's the patient's Left or Right, not yours.

Sent from my iPhone -- blame all errors on spellcheck

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Specializes in Emergency & Trauma/Adult ICU.

Good grief.

What is most significant to me about this is that you said this has generated "debate". So others are also confused about anatomical position?

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Oh my goodness. I was going to use an example of which side is the patient's heart when charting but the amputation example is so much better.

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Specializes in Med/Surg/ICU/Stepdown.

I can only speak to how I document assessments, and in that case, I always refer to the "patient's left/right (insert body part)."

It's about the location of the injury ON the patient. It isn't documented utilizing the viewer's POV, particularly when you're describing an injury which is subjective in nature, not objective.

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Specializes in Emergency Psych, ICU.
It's the right side of HIS body. It should be documented as the right side. Try pointing it out this way to her: If a surgeon is going to amputate the right foot for a non-healing ulcer, what food should he amputate? The patients right foot, or the left foot because it's on the surgeons right?

Looking at things that way, if she doesn't change her statement then... I'm just hoping I don't have to be the patient

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Specializes in LTC Rehab Med/Surg.
There is no debate. The patient's left eye is always going to be the patient's left eye.

The fact that you had to post this is hilarious.

I'm not even sure it was supposed to be funny.

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