stupid documentation!

[NC29mom]

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????

[NC29mom, ASN, LPN, RN]

just forget it.............amazing how 2 people point out my typo on "documentate".

petty, indeed./

[MrsCrypes]

WHOA!

Hello! Documentation is soooo freaking important and at times, can make you or break you. Oh Gosh!

In nursing school, didn't we learn our lesson and scared straight about how documentation, BAD documentation can have your license (which we all worked so very hard for) revoked?

You can keep telling a nurse how to document and some will take your advice, and others will continue to do what they want. Just make sure you are straight on your documentation

Nurses who document erroneously are making these lawyers look good and are making them money as they fault the nurse on everything

[Lorrie34]

OMG, I don't know what to say about those nurse's notes! At the LTF where I work, we have regular inservices on documentation. Our nurse educator even gave us a written test on it for our employment records. She audits our charting regularly. "Nurse's notes should be a storybook of the care provided to that resident" is what she always tells us. When I enter my nurse's notes, I always remember that and I make sure I include all the interventions and if a resident has a specific complaint that sounds like a med. dx, I put it in quotes (like: resident states "I think I'm having a stronke") to cover my butt.

Remembering to make it a "storybook of the care provided" helps me to remember to dot all the i's and cross all the t's in my notes. I describe colors and hues of bodily fluids too! I may have a longer note than some other nurses, but at least when they read mine, they feel like they were there and saw it themselves! LOL

[Baloney Amputation, BSN, LPN, RN]

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.

I totally agree about quotes versus paraphrasing. I would never chart like the OP's example, and I think its atrocious charting. However, knowing some fabulous nurses who aren't necessarily the best with their written words, I tried to give the benefit of the doubt that the charting nurse (in the case of the #2 example) wasn't purposefully making a jab at the OP. I understand that there could possibly be far-reaching implications by the poor choice of words, though...

[leslie :-D]

i know easier said than done, but someone needs to approach the administrator and share concerns.

maybe s/he will get the staff inserviced on documentation.

it's really unfortunate (and scary) the DON is being so apathetic...s/he sounds very inexperienced as well.

place an anonymous note under the admin's door, explaining the risks that such documentation, endangers the licensing of the facility.

hopefuly that will be enough to get some much-needed inservices.

if not, the state will let you know with a lot of demerits, when they come in for their annual survey...

which is public knowledge and will cast a negative light on the facility.

sheesh...are you sure these folks are nurses????

leslie

[EmmyBee]

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

This was funny. I think in order for a person to be embarrassed, they'd have to actually know that what they wrote was incorrect. These nurses probably wouldn't see anything wrong with their documentation. And they would spell out loudly, with pride, in court. LOL

I work hospice right now, and I have seen some pretty horrible documentation. But for the area I live in, it's common to have people working, who don't speak English very well. So I figure that is why some of the notes are poorly written. But sometimes it still makes me shake my head.

OP- I think most people took your post seriously. No one is perfect. And I'm sure most, if not all, of us on here have made our fair share of typos. They will happen from time to time.

But it's more than that in the examples you listed. The entries were very vague and didn't tell what was really going on with the patient. Symptoms, or lack thereof, should be written out, in order for there to be no mistake, of what the patient was or was not experiencing. And "fof"? Was that supposed to be "fell on floor"?

Hopefully your facility takes this seriously, and gets some type of inservice or classes on documentation in order.

[Baloney Amputation, BSN, LPN, RN]

just forget it.............amazing how 2 people point out my typo on "documentate".

petty, indeed./

just forget what? a lot of people took a little time out of their day to post in this thread to agree with you. so a couple of people pointed out a small error in your post. no one likes to be on the receiving end of it.

[dudette10, MSN, RN]

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.

...is impeccable.

"Communication" is not a collective noun.

I love grammar correction posts!

[Pepper The Cat, BSN, RN]

Some of the documentation I see is enough to give me nightmares.

We have an RN with 25 years exp who writes the worst progress notes. First of all - she types in all caps -which is really hard to read, esp when her notes are really really long. And full of crap. Once she wrote about how she told a pt's daughter that the daughter "really needed to help out more when her Mom went home and how she needed to stop being so selfish" She then went on to describe how she sharer her (the RNs) practise of helping her own Mom. The note went on and on and was really inappropriate.

Another time she wrote that a pt's son "needed to be spoken with in a firm voice and not permitted to dictate things to the nurse" and how she "informed the MD of this before letting the MD speak with the son". Now - we all know there are people out there that need to be dealt with firmly but this does not belong in a chart!

And my current fav - written by one of our discharge planners. The pts sex changed several times throughout her note. First the pt was referred to as "he" then "she" then "he" and so forth.

Going back to the first RN again - she once wrote on a pt who was dying that "pt was calm and accepting of his fate and was prepared to meet his death peacefully". Don't know how she knew this - pt did not speak English and family was never around!

[SmilingBluEyes]

I always tell coworkers feel free to inform me if my charting is lacking or is grammatically-poor. It's that important to me. And yes, I want people here to correct me too. I don't want to sound like and appear to be an idiot! And I sure don't want my charting up on a HUGE screen in a court room any time, but ESPECIALLY if it's deficient!

[NC29mom, ASN, LPN, RN]

as a matter of fact, somebody beat me to putting a note under the administrator's door - we had a nurses meeting, but it was related to other problems in the facility.

don't get me wrong, i wasn't trying to bash the facility where i work. in fact, i have never worked anywhere else. i love it that much!! it just aggrevates me a bit to see charting consisting of the material i listed in my first post. it saddens me also. i have spoken up numerous times, but nothing was ever done. my don is a great person, but maybe not a great don. she tries to "get along" with everyone. i think there are certain circumstances where she should stand up and speak up. but............................i have no control over her actions.

my main thing was to just get people to think when they document. i take my documentation very seriously. at times, i probably document too much.

thanks for the input! i really enjoyed reading.....

[Jolie, BSN]

edit.