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????

[dudette10, MSN, RN]

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.

There is definitely truth in this. I can only use the example of my father, who was a brilliant man, but he couldn't spell or use proper punctuation and grammar if his life depended on it. He worked his way up to a supervisory position in his line of work (a policeman), and he would occasionally have to write reports.

When I was about 15, he would regularly have me edit his reports for him (under strict secrecy because of confidentiality issues) because he understood the value of proper documentation. As I said, he was a brilliant man, but he also knew where he needed help, and he definitely swallowed his pride in allowing his 15-year old daughter do editing for him.

My POV on this issue is that a lack of writing skills does not indicate the intelligence of the writer; however, not recognizing it and taking steps to improve does indeed reflect on us.

This applies in the professional arena, though, not a message board. My writing skills have been honed over years of doing it professionally, but you will still see many mistakes--hopefully just minor ones--in my MB posts because this is an entirely informal medium in which I write as I think and often skip proofreading.

[carolinapooh, BSN, RN]

Anyone else think all the "txting" is doing no one (specifically in the "txting" generation) any favors? Just curious.

[cicatrixx15]

Anyone else think all the "txting" is doing no one (specifically in the "txting" generation) any favors? Just curious.

I can't stand reading text talk. It's annoying on a phone, but even more obnoxious on message boards or in e-mails. Of course, I'm one of those people that capitalizes and punctuates my texts.

[carolinapooh, BSN, RN]

I can't stand reading text talk. It's annoying on a phone, but even more obnoxious on message boards or in e-mails. Of course, I'm one of those people that capitalizes and punctuates my texts.

Am I glad to find a kindred spirit - my texts take FOREVER...easier now with an iPhone with a real keyboard! I was a nightmare with a regular phone.

[Katie5]

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.

You gave a very encouraging and non-judgmental correction, but no where do I see where you wrote out a correct version for the word, "grammer" (Grammar):)

[NC29mom, ASN, LPN, RN]

Thanks dudette10 - it is important in a professional situation, not pertaining to message boards - Don't understand why everyone is repeatly pointing out my errors - I never said I was perfect either (and for the 10th time - THIS IS NOT A MEDICAL RECORD)!!!. I can promise you my documentation is not even close to some of my co-workers.

The point of the conversation being, that some of us are probably more conscious of our documentation than others. And, that REPEATEDLY documenting in the way shown makes the nurse seem very uneducated and unprofessional.

[leslie :-D]

Don't understand why everyone is repeatly pointing out my errors - I never said I was perfect either (and for the 10th time - THIS IS NOT A MEDICAL RECORD)!!!. I can promise you my documentation is not even close to some of my co-workers.

The point of the conversation being, that some of us are probably more conscious of our documentation than others. And, that REPEATEDLY documenting in the way shown makes the nurse seem very uneducated and unprofessional.

well, considering that you would likely write grammar as "grammer" in a medical record, the point is that there's a good chance the writers, are unaware of their spelling errors...just as you were unaware.

i truly don't understand why you are getting so huffy.

politely point out our errors (not typos), only makes us more educated, yes?:)

none of us are beyond (constructive) criticism.

leslie

[Baloney Amputation, BSN, LPN, RN]

You gave a very encouraging and non-judgmental correction, but no where do I see where you wrote out a correct version for the word, "grammer" (Grammar):)

That's why I put it in quotes. I definitely know how to spell grammar (and aggravated, for that matter), which is why I made the post in the first place. I know I learn best when I look up my mistakes for myself and see what I did wrong, so that's why I left the misspellings in quotes without typing the corrections. I trusted that the OP could figure them out for herself when alerted to the errors.

[jennahousern, RN]

I understand your pain, however, pt charts are legal documents. When notes are not done correctly to include proper spelling or grammar there are adverse effects. The bottom line is that it could harm the pt, an error in doc. can kill a pt cause malpractice and negligent lawsuits and maybe even cost you your job. ultimately, you are correct in trying to improve upon these skills. Take a writing course, use spelling check and or type note in a word program where grammar is checked and then cut and paste to its proper place. If its a paper chart then this is a little more difficult to do. Good luck!

[carolmaccas66, BSN, RN]

I just lost another long post on here AGAIN!! It's starting to p**s me off!

Basically I said a senior nurse I knew who r/v documentation, (& who trained in law also) said if you don't know what ur talking about (and a university trained nurse SHOULD know nursing/medical terminology), it can lead to errors & misundestandings. It can also hold you open for liability in court. you SHOULD know what you're writing about.

I'd be telling these nurses to their faces that they can be held accountable if a patient dies, it goes to court & they will look pretty stupid when these examples are read out. They won't be able to adequately explain themselves either.

Were they from another country? I've worked with asian and indian nurses and they have a different way of looking @ & writing things - I bet English is not their first language.