The word NO

[SBehanna]

We were told not to use the word No in documentation. So how would you phrase "No edema in lower extremities". How do you get around the word No? Also where can you find examples of wording in nursing documentation /charting. It would be nice to know how to word things when you have never done it before. Would appreciate any help. Thanks

[SBehanna]

Thank you all so much for the input. I have no idea why we can't use the word no. I can understand not using the word normal since "normal" is different for everyone. I do appreciate all the replys. You guys are great !! Thanks !!

[BigRussKCMO]

No means Yes

[greenfiremajick]

We were told not to use the word No in documentation. So how would you phrase "No edema in lower extremities". How do you get around the word No? Also where can you find examples of wording in nursing documentation /charting. It would be nice to know how to word things when you have never done it before. Would appreciate any help. Thanks

Zero

absent of

lacking any

negative presence of

[miss81, BSN, RN]

We use normal sometimes too. Like "IV site within normal limits". That's actually the option on our computer charting system. We use "No" as well. For assessing a wound, "No redness or dehiscence noted..." Man I hate how some nurses and management try to complicated things. Did you learn this in nursing school or is it something from a new job???

[NurseCard, ADN]

Edema challenged.

[donnasRN]

I think the person who told you not to use the word "no" has heard of charting by exception but not quite grasped it. He or she was probably taught not to chart normal findings and given several examples that began with "no this" and "no that", then twisted that into an absurd rule.

If it's really just one person's silly idea that it's taboo to use the word no - a simple (if somewhat smartass) way to get around it would be to substitute 0. On my unit we chart by hand and we all use 0 with a line through it as short for no or not.

Good luck staying sane,

Rhymeswithlibrarian

Totally agree. At my facility, the vocabulary we're allowed to use is constantly changing and no one has a reason for it LOL! It's probably due to them catching wind of something that was documented in another agency/different unit in which JCAHO/OMH had an issue with so they take it to the extreme to cover themselves.

[blondy2061h, MSN, RN]

Zero

absent of

lacking any

negative presence of

"Negative presence of" seems way more confusing than "no."

[Tait, MSN, RN]

Edema challenged.

LOL

:chuckle

[HmarieD]

Be careful with charting by exception. Lawyers have a field day with it. I try as often as possible to document "pt denies ___ (pain, SOB, chest pain, etc etc). It indicates that you did assess and had negative findings which the pt reinforced. CYA at all times.

[nerdtonurse?, BSN, RN]

Your job, your license. I chart what I need to chart to CYA. I don't chart by exception, because I chart what I did; I don't like signing off on just anybody else's assessment.

If you've got no choice (and I'm sure wondering what happened -- did a lawyer told the facility to never use "no" again -- sounds like someone wrote a "no" that should have been a "yes" and got sued) -- I would do "negative for: edema, pain, n/v....), whatever.

[fins]

One possible reason for not using the word no would only apply to written charting, and that is the fact that "no" is such a small word. When you have people whose handwriting looks like they use their elbows to write, "absence of" gives you more of a fighting chance than "no." We've all had those "what does this say" chart parties. "Hey, Lisa! Does this say 'no BM' or '10 BM' ?"

[boggle, ASN, RN]

Can't us the word "no"? I just don't understand the reason for that. Why make charting more unclear?

Sigh