stupid documentation!

Don't use Med dx in note unless as a quote from a patient. For CVA: Pt c/o left arm weakness and decreased sensation. Equal mobility, grip strength, etc noted...Blah, Blah, Blah. Someone needs to do some education with the staff. The poor notes will get them in trouble with DOH or other legal entities. Do you have some policy on documentation to provide guidleines? Honestly, if the care for CVA and chest pain etc. really consists of what is in the note, they deserve to be in trouble.

don't use med dx in note unless as a quote from a patient. for cva: pt c/o left arm weakness and decreased sensation. equal mobility, grip strength, etc noted...blah, blah, blah. someone needs to do some education with the staff. the poor notes will get them in trouble with doh or other legal entities. do you have some policy on documentation to provide guidleines? honestly, if the care for cva and chest pain etc. really consists of what is in the note, they deserve to be in trouble.

i totally agree! i have talked to my don until i am blue in the face. i went to her about the nurse putting in the note "day nurse couldn't decide if she had heart attact". i told her, "we are here to cover each others backs, not stab each other in the back" and she agreed. did she ever say anything to that nurse? no. but, i did. it's amazing to me they still have a job with some of the stupid crap they do. and the cva note, omg - i was shocked anybody with any amount of sense would document that - but, she did. and the don read the note, and said nothing. it is scary though, because these are my patient's they are caring for. and yes, education (if you would call it that), has been provided. we do have a policy, and i refer to it often, but it does no good when the don doesn't enforce it.

i love where i work, but i disagree with my don's approach at handling problems. she just ignores them.

That is some of the worst documentation I have ever read. It tells me nothing, yet it opens a whole Pandora's box of possibilities. Misspellings aside, it contains nothing of value to anyone who would read it afterward. They are just notes for the sake of notes. I wouldn't want to have to go to court with only this to back me up.

A heart attact. Really? REALLY?

And the DON saw nothing wrong with that particular piece of, er, documentation?

You may love your place of employment but either you need to take your concerns to the DON and the staff educator (if you have one---maybe he/she will listen) or start to dust off your resume. This kind of nonsense could cost you your license if there was a lawsuit or get all of you in a spot of trouble if the state surveyors see it.

2. Pt c/o chest pain and says that day nurse couldn't decide if she had a heart attact. No signs of heart attact noted. (nurse actually spelled heart attack as 'heart attact')

That scares me on so many levels. I think you should run before someone's inability to chart properly results in negative consequences for you.

In the facility where I am employed, charting is reviewed on a daily basis by the ADON, as the info presented @ morning report is drawn from the previous 24 hours' charting.

what kind of "nurse" is charting as described above?

wow, scoochy, that's a fantastic idea for the adon to review the documentation. actually, we don't have an adon at the moment. i have informed my don i am interested in the job and just waiting to hear. hopefully, i will get the position and be able to provide better & more education on documentation. i also would love to make a few other changes.......

wow, scoochy, that's a fantastic idea for the adon to review the documentation. actually, we don't have an adon at the moment. i have informed my don i am interested in the job and just waiting to hear. hopefully, i will get the position and be able to provide better & more education on documentation. i also would love to make a few other changes.......

i hope you get it---especially since you otherwise enjoy working there, it could be a very good fit for you! good luck!

Let me tell you....if you ever get called for a deposition on that charting...you are hosed. I've been called x2 and had to read other people's stupid stuff and the other attorney just fed off of it. You DON needs to step up to the plate!

Is your "DON" literate and/or competent?

Why not look for a job where coworkers are higher functioning?

wow that's horribly irresponsible! Where is your DON? Ours would send those right back and tell us to delete them or make corrections. We aren't allowed to be subjective, in fact no one is. I'd hate to see those nurses in front of a smart a$$ lawyer!

Bad documentation coupled with horrible use of tenses and spelling. We should always try to draw a picture with our documentations I've been told. It does not have to be overly wordy but just enough to give the next person what there is to know.

Yes, this may open a can of worms, but what title do these nurses hold? Sometimes people do things because they know no better or that is where their knowledge begins...(or ends).

Not that that is much of an excuse though...