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????

[Moogie]

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.....

you weren't attacked. you were "attacted".

[Moogie]

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.

Seriously, I do agree with this. I'm old school, too, and learned that sloppy documentation not only made the nurse seem ignorant, it also cast uncertainty upon the accuracy of his/her assessment. Sometimes mistakes are made because people are in a hurry. But consistently poor documentation is troubling and it's something that should be addressed in nursing school, particularly when the other standards are so high.

I don't understand why nurses and nurse educators, who hold themselves to high standards in terms of skill mastery, scientific knowledge, and critical thinking are so lax in terms of grammar. I've seen papers at the baccalaureate and graduate level that are full of grammatical and spelling errors and I cannot understand why some of these students don't take advantage of writing labs and resources available at their schools.

Then again, I once had a DON who couldn't spell and had atrocious grammar. Her lack of skill in written communication was inexcusable, unprofessional, and a poor example for the rest of the staff.

[leslie :-D]

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

very true, les.

and still, the poor spellers are those who usually insist it's no big deal...

and it's the quality of their care that counts.

it all counts.

leslie

[TDCHIM]

I don't understand why nurses and nurse educators, who hold themselves to high standards in terms of skill mastery, scientific knowledge, and critical thinking are so lax in terms of grammar. I've seen papers at the baccalaureate and graduate level that are full of grammatical and spelling errors and I cannot understand why some of these students don't take advantage of writing labs and resources available at their schools.

Oh come now, Moogie, that would take extra effort! Horror of horrors!

That seems to be the attitude among some of my classmates, anyway.

[NC29mom, ASN, LPN, RN]

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.

it's the way you said it, dear.

[Penelope_Pitstop, BSN, RN]

You weren't attacked. You were "attacted".

I just sucked Mello Yello into my brain...

[NC29mom, ASN, LPN, RN]

the notes i posted were actual documentation entries, they were not made up or changed. they speak for themselves. that's not to say i don't make mistakes myself. but, i don't document using the language or subjective data that some of my co-workers use. and, the nurses consistently document in a poor manner. i take my job very seriously. (and this post isn't a medical record -- the documentation i included was in a medical record).

i started the post because i was slightly aggrevated with the less than average documentation i deal with daily. it's very hard to provide 'continuity of care' when the pictures being painted are as i posted.

i spend time every week on this website reading the threads from others. and, i do it to learn more about how other nurses are feeling about their jobs or situations on the job. this site, i am sure, was started so we could interact with each other and learn from each other.

midwest4me, i agree with you! nurses are judged by their actions - including documentation. the documentation not only speaks about the patient, but about the nurse. the grammer mistakes i can handle more than the lack of assessment information. i ask a lot of questions, sometimes too many (i'm sure). but, you have to in order to provide responsible care. unfortunately, the documentation i used in my first post came from girls who have been nurses for 10+ years.

moogie funny, my nursing instructors said the same thing (about receiving papers with tons of grammer and spelling errors). it's almost inexcusable now with microsoft word and perrla programs that automatically point out grammer and spelling errors. i wish we had a spell/grammer check on our electronic medical record program, but we don't - and even if we did - i wonder if anyone would use it. the poor documentation is an ongoing problem, almost every day i read a note and think, "what??"

[NC29mom, ASN, LPN, RN]

you weren't attacked. you were "attacted".

omg that is tooooooo funny! thanks for bringing some laughter into the conversation!

[Jolie, BSN]

it's the way you said it, dear.

what wording would you find acceptable?

[Moogie]

:brnfrt:

never mind....

[nursel56]

QUOTE=Lorrie34;4341559]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.

I really wish we had more inservice on that for our homecare nurses, who it seems have taken the "storybook" idea to unimaginable extremes of superfluous and wholly unnecessary details, since 80% of our record is in the form of a Flow Sheet. The small area for commentary, as I understood it, was meant for pertinent details directly pertaining to changes in status or other specifics targeted to the patient's diagnosis.

What I read (if I can manage to decipher the tiny little writing squinched into the limited space)

"pt watching the movie "OLIVER" on tv - seemed to enjoy" then filled humidifier with water patient tolerated well placed hand on table x4 changed vent filter pt tolerated well pulled up blanket

and on to form a solid cryptic wall no one will ever read so I hope nothing important is in there. Yeah, OK. "If it's not documented it isn't done" but you handed the patient his slippers x3??

It's like Pepper the Cat's nurse with the wacky stuff written in longhand. . .and when you are charting more is not necessarily better. Can't seem to get any agreement on that point, though. --sigh--

[Baloney Amputation, BSN, LPN, RN]

the notes i posted were actual documentation entries, they were not made up or changed. they speak for themselves. that's not to say i don't make mistakes myself. but, i don't document using the language or subjective data that some of my co-workers use. and, the nurses consistently document in a poor manner. i take my job very seriously. (and this post isn't a medical record -- the documentation i included was in a medical record).

i started the post because i was slightly aggrevated with the less than average documentation i deal with daily. it's very hard to provide 'continuity of care' when the pictures being painted are as i posted.

i spend time every week on this website reading the threads from others. and, i do it to learn more about how other nurses are feeling about their jobs or situations on the job. this site, i am sure, was started so we could interact with each other and learn from each other.

midwest4me, i agree with you! nurses are judged by their actions - including documentation. the documentation not only speaks about the patient, but about the nurse. the grammer mistakes i can handle more than the lack of assessment information. i ask a lot of questions, sometimes too many (i'm sure). but, you have to in order to provide responsible care. unfortunately, the documentation i used in my first post came from girls who have been nurses for 10+ years.

moogie funny, my nursing instructors said the same thing (about receiving papers with tons of grammer and spelling errors). it's almost inexcusable now with microsoft word and perrla programs that automatically point out grammer and spelling errors. i wish we had a spell/grammer check on our electronic medical record program, but we don't - and even if we did - i wonder if anyone would use it. the poor documentation is an ongoing problem, almost every day i read a note and think, "what??"

i know there are a few out there not speaking up but are wanting to do so, but i will just for future reference. the word you intended to type is not spelled "grammer." the word spelled as "aggrevated" was only used once, so that may be a mistype. however, i see "grammer" 3 times spelled this way. please take this as a friendly post, because it is. i cringe when my errors are pointed out to me in my line of work (not nursing), but i choose to swallow my pride and learn from the errors.