stupid documentation!

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excuse me while i rant.................. i work in a ltc facility with a few nurses who just drive me crazy with their documentation!!!! (we have electronic medical records) i remind them nicely that the nurses notes are part of the medical record and to please use some common sense when documentating. here are a few examples for your amusement:

1. pt complained she had stroke. tested by giving glass of water to see if patient could swallow. water swallowed. no more complaints.

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')

3. pt were up in hallway when he fof. too cnas at side. no injuries.

4. foley cateter were in place at beginning at shift. found pipe on floor. dr informed.

***by the way, the "day nurse" that #2 was referring to was me! talk about ****** off! i confronted the nurse and reminded her the patient has dx of dementia, and even if she said that - why the he** would you put it in the record????? of course i didn't tell the patient that non-sense. anyway, it's really not funny..................but these were the main ones that came to mind when writing this post.

whatever happened to objective charting? assessments? "no injuries" is way to vague, how about: moves all extremities, has full rom, etc..

anybody got anymore to contribute????

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...

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Specializes in LTC, Acute Care.

On the other side of things, I don't think the #2 item was a swipe at you. It does say that the patient in the #2 item was the one who stated the day shift nurse couldn't decide if pt was having a "heart attact," not the charting nurse making that judgment. If it is known that this patient is demented, this could just be a behavior that should be charted, especially if the patient continues to say things to the effect of putting one nurse's judgment against another nurse or make up stories or whatever else.

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Specializes in LTC.
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...

It's clear that the poor documentation is a reflection of a lack of education but I don't believe title has anything to do with it.

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On the other side of things, I don't think the #2 item was a swipe at you. It does say that the patient in the #2 item was the one who stated the day shift nurse couldn't decide if pt was having a "heart attact," not the charting nurse making that judgment. If it is known that this patient is demented, this could just be a behavior that should be charted, especially if the patient continues to say things to the effect of putting one nurse's judgment against another nurse or make up stories or whatever else.

Then it should be in quote, exactly the way it was said. Some things just should not be paraphrased. Reading it the way it is, sends all kinds of different messages.If a patient is at risk for CVA, what steps did Day nurse take.

Speaking of which, did the current nurse get vitals on her patient, if for nothing else, at least to have a baseline, for when she took over the shift. I don't presume to know a whole lot, but I know enough that one must always give no room for doubt. As the saying goes, if you didn't chart it- you didn't do it.

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It's clear that the poor documentation is a reflection of a lack of education but I don't believe title has anything to do with it.

I'm putting it together as lack of education leading to the nurses not understanding the consequences of their documentations or lack thereof.

Yes?

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Specializes in LTC.

LPNs are taught to document correctly and the reasons why, including implications of not doing so, if that's what you're getting at.

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Specializes in Hospice, corrections, psychiatry, rehab, LTC.
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')

This note in particular is disturbing. Aside from the nurse's inability to spell "attack" (thereby calling her medical knowledge and competence into question), it says nothing about what the nurse did to so casually dismiss a symptom of a potentially life-threatening condition. She also insinuated that you had no idea what was going on (which I would never chart, even if it were true). If this patient had died of an MI, God help this nurse and your facility. Hopefully you would not have gotten dragged into it as well.

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During the course of the lawsuit I was involved in, we went over my documentation shift by shift, word for word. I can imagine my embarrassment if I would have been discussing the above with educated attorneys! Can you imagine the above being read aloud in a courtroom, to include spelling out the words? I was told to spell out the "big" words. Attact. A-T-T-A-C-T

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Specializes in Maternal - Child Health.
excuse me while i rant.................. and to please use some common sense when documentating.

i wouldn't bring this up, except that you have posted about others' poor grasp of the english language, including grammar and proper word usage.

do you really "documentate?"

i agree that your co-workers need to get their charting in order, but your comments will be taken much more seriously if your written communication are impeccable.

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I wouldn't bring this up, except that you have posted about others' poor grasp of the English language, including grammar and proper word usage.

Do you really "documentate?"

I agree that your co-workers need to get their charting in order, but your comments will be taken much more seriously if your written communication are impeccable.

I second this - Should you feel the need to rant about documentation in the future, please be aware that "documentate" is not a word. Instead I suggest that you use "document" which is a word.:up:

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Specializes in ER/Geriatrics.

petty and condescending feedback in my opinion.

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Specializes in Hospice, Geriatrics, Wounds.
i wouldn't bring this up, except that you have posted about others' poor grasp of the english language, including grammar and proper word usage.

do you really "documentate?"

i agree that your co-workers need to get their charting in order, but your comments will be taken much more seriously if your written communication are impeccable.

are you serious?????????:??

excuse me, but my use of "documentate" was a typo. sometimes my thoughts are faster than my hands. and, may i point out, this is not a medical record.

amazing, to get attacked when starting a thread. never mind.....:down:

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