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 15 years in ICU, 22 years in PACU.
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.

So many questions ; so little space.

Are you a troll?

Is the other nurse dyslexic?

Could the patient possibly have two left eyes?

Are you located in the southern hemisphere?

Does your facility have a lot of mirrors?

What kind of nursing degree does the other nurse have?

Have I completely lost all faith in the intelligence of humanity?

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

This is the only thing that makes sense. No one has EVER been taught to chart something right/left based on their (examiner's) point of view.

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For the love of Florence, please tell me you don't work in neuro. STAT head CT's for everybody!

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Are you located in the southern hemisphere?

Does your facility have a lot of mirrors?

These are the best questions ever. Ever.

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She is mistaken. Would she chart differently if she was standing behind the patient and assessing a surgical incision to the back?

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Specializes in Psych ICU, addictions.

Another vote for "you chart where it is located on the patient."

What you coworker is suggesting makes absolutely no sense...as well as being potentially dangerous to the patient.

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Oh my goodness!

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Specializes in Emergency Nursing.

Are you located in the southern hemisphere?

Hey, hey there now. Easy there. I'm located in the Southern Hemisphere and I do know how to correctly assess a patient. Lol

I'm not telling you it's going to be easy, I'm telling you it's going to be worth it.

Author: Art Williams

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Specializes in 15 years in ICU, 22 years in PACU.
Hey, hey there now. Easy there. I'm located in the Southern Hemisphere and I do know how to correctly assess a patient. Lol

Now I'm not sayin' you're backward or anything, but which way does your toilet swirl? To the right or to the left?;)

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Specializes in Emergency Nursing.
Now I'm not sayin' you're backward or anything, but which way does your toilet swirl? To the right or to the left?;)

Oh Jesus.

I don't know 😋 My toilet isn't a patient so I don't try to assess which way it flushes. I'll try to take the time and check that out next time though. Haha

I'm not telling you it's going to be easy, I'm telling you it's going to be worth it.

Author: Art Williams

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Specializes in Post Anesthesia.

It's funny-but this has caused much confusion between my family and friends and myself. I look at a patient and his boo-boo is on his right arm (the one nearest to my left.) I do call that his right arm. But. if I say " look at the TV-, see the kitty cat there on the right?" I'm refering to the oposite side from the one I called "right" when referring to a patient. I have, at least once a week forgotten and reversed the intended direction when referring to the TV, or some other non-animate object. Makes my wife CRAZY!

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Specializes in Peds/outpatient FP,derm,allergy/private duty.
confused.gif I guess if two nurses needed to work together standing on opposite sides of the patient's bed you'd have a High Noon standoff or a funny skit like Monty Python Argument Clinic? "The injury is on the right side!" "'Tis not! It's on the left side!" etc -- maybe the patient could chime in and break the tie? This is so silly!
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