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Discussion

Track Marks

My nursing notes is a majority of my charting. I use narrative to document a pts stay from triage to admission / discharge. Still to this day, I have not created a generalized note to describe pts track marks. I want to be as objective as possible; however, it is difficult to chart track marks without charting opinion. The term "track marks" automatically implies opinion.

Does anyone have a simple yet legal way to document the evidence of IV drug use?

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    Linear, slightly raised discolorations noted to left wrist. Pt admits/denies iv drug use.

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    As Sassy said, document what your see/what the marks look like, not what you think (even if you are 99.99% sure) they are. If someone else wants to form an opinion based on the appearance of the marks, that is on him/her.

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    • Moderator

    Small punctures in various stages of healing, perhaps? Edema, erythema, scabbing, etc. I would just describe what the wound looks like, and wisely skip anything that sounds like social commentary.

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