stupid documentation!

Nurses General Nursing

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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????

Specializes in Maternal - Child Health.
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:

...is impeccable.

"communication" is not a collective noun.

i love grammar correction posts! :clown:

point taken. i'll accept your constructive input and not accuse you of attacking me!

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Specializes in Hospice, Geriatrics, Wounds.
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:

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! :clown:

thank you. i was going to point it out also, but i was trying to be nice.

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Specializes in Maternal - Child Health.
thank you. i was going to point it out also, but i was trying to be nice.

there's nothing unkind about an objective correction. had dudette mocked my intelligence, education, experience, professionalism or practice (as other posters did in regard to your examples), she would have been unkind. she simply pointed out an error similar to the one i was highlighting (great parallel there :).) that's not at all unkind; it's actually quite helpful.

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Specializes in Operating Room Nursing.
just forget it.............amazing how 2 people point out my typo on "documentate".

petty, indeed./

isn't it meant to be too people? lol

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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 could not help it, LOL-the hunter becomes the hunted:)

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Specializes in A myriad of specialties.
Isn't it meant to be too people? Lol

No, it should be TWO(she abbreviated it by using the number 2). The word "too" would NOT have made sense in that statement.

It's really unfortunate (and continues to AMAZE me) that with the unbelievably HIGH standards nursing schools have these days(i.e. the requirement of straight A's), nurses are continually allowed to graduate without having mastered proper documenting skills!! The OP's documentation examples in the first post are pathetic! I liken it to dressing like a slob for an interview. It shows lack of interest. Appearances are often everything. More often than not, a nurse's intelligence is judged by his/her documentation. Many may say "that's not fair" but in this economy, with this job market the way it is, grammatically correct documentation is most definitely a required skill. Just my two-cents' worth; I'm an old nurse and learned from the best.

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Specializes in Operating Room Nursing.
no, it should be two(she abbreviated it by using the number 2). the word "too" would not have made sense in that statement.

ha ha i was referring back to '3. pt were up in hallway when he fof. too cnas at side. no injuries.':lol2:

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It's really unfortunate (and continues to AMAZE me) that with the unbelievably HIGH standards nursing schools have these days(i.e. the requirement of straight A's), nurses are continually allowed to graduate without having mastered proper documenting skills!! The OP's documentation examples in the first post are pathetic! I liken it to dressing like a slob for an interview. It shows lack of interest. Appearances are often everything. More often than not, a nurse's intelligence is judged by his/her documentation. Many may say "that's not fair" but in this economy, with this job market the way it is, grammatically correct documentation is most definitely a required skill. Just my two-cents' worth; I'm an old nurse and learned from the best.

i'm with you, midwest.

and if we dare point out the errors, we're accused of "attacks" or better yet, eating our young.

my only hope is, it won't take 20 yrs (when they reach our age) for them to get that "aha" moment, to finally understand that we were right...

that image IS everything, whether r/t how we appear in person, or on paper.

leslie

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Some can point out errors or make constructive suggestions, but others are not allowed that privilege.

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Specializes in Med/Surg, Academics.
It's really unfortunate (and continues to AMAZE me) that with the unbelievably HIGH standards nursing schools have these days(i.e. the requirement of straight A's), nurses are continually allowed to graduate without having mastered proper documenting skills!!

Agreed.

I often get frustrated with nursing school because so much of what we will be expected to do straight out of the gate is off limits to us, except for (I hope) our senior practicum. In my current rotation, we can complete the flowchart (which is all symbols and such), but we can't document with narrative on the "nurse's notes" section of the flowchart. Will a nurse's note not even be written if I and my clinical instructor are the only ones in the room for the initial assessments and subsequent rounds?

It's frustrating to me.

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i'm with you, midwest.

and if we dare point out the errors, we're accused of "attacks" or better yet, eating our young.

my only hope is, it won't take 20 yrs (when they reach our age) for them to get that "aha" moment, to finally understand that we were right...

that image IS everything, whether r/t how we appear in person, or on paper.

leslie

I beg to differ. Most times, it is the older nurses who can't spell or make use of simple tenses. Their excuse, "It's not my fault that I can't spell."

Ludicrous!

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Specializes in LTC.

I've seen bad grammar and spelling from both camps.

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