Unprofessional charting

[Nurse131382]

I work on a busy cardiac floor and most of our PCT's don't make hourly observations in the EHR. However we have one who does and it is riddled with spelling and grammar errors. It also doesn't include what I perceive as important information that needs to be charted. For example "patient sitting in chair eating a piece of candy, does not like what is on TV and says the hospital food is gross ". Is this something that should be corrected or is it just a matter of opinion on what is good vs. Bad documentation.

[Purple_roses]

I personally think it's evident that she doesn't know how to chart properly. What she charted is harmless, but she seems to chart whatever floats into her mind, which is where I personally could see a problem coming into play.

When someone does not know how to chart something properly, that person may accidentally chart something that could get the floor into legal trouble. One of my instructors addressed this topic this semester. If a lawsuit should ever arise, that charting will be scrutinized for any tiny detail that seems off. Even if nothing "bad" happened on the floor, it's too easy to chart something in an inflammatory manner, and that gets people into trouble.

[TheCommuter, BSN, RN]

Years ago, when I worked as a floor nurse at a SNF, one of my coworkers charted a lengthy narrative note about a dietary aide who provided one of the patients with plastic cutlery (fork, spoon & knife).

A state surveyor read this note several months later during a full-book survey and was unimpressed. The facility was cited for 'quality' issues (e.g., patients who are not on isolation deserve stainless steel cutlery).

This is an example of a facility paying the price for a nurses note about an occurrence that never should have been charted in the first place.

[applesxoranges, BSN, RN]

I select "no apparent distress" and "assistance offered" and then usually chart patient location, if there is food, and activity. Patient sleeping at this time. Patient watching TV in bed. Crackers given to patient. Stuff like that. That way when patient insists I don't offer them food I can look at the chart.

[TriciaJ, RN]

I personally think it's evident that she doesn't know how to chart properly. What she charted is harmless, but she seems to chart whatever floats into her mind, which is where I personally could see a problem coming into play.

When someone does not know how to chart something properly, that person may accidentally chart something that could get the floor into legal trouble. One of my instructors addressed this topic this semester. If a lawsuit should ever arise, that charting will be scrutinized for any tiny detail that seems off. Even if nothing "bad" happened on the floor, it's too easy to chart something in an inflammatory manner, and that gets people into trouble.

I couldn't agree more. In the event of a lawsuit, poor charting (even seemingly innocuous) will sink a facility. There's a reason aides don't do narrative charting in most places and even nurses should have stronger charting skills than many do.

Nothing tightens my jaws more than medical charting (which is a legal document) that makes the writer appear semi-literate.

[cayenne06, MSN, CNM]

If PCTs are charting narrative notes, they should be given the training to do so correctly, just like any other skill. Most of my CAs (clinic assistants) are good charters, but I had one that would CHART EVERYTHING IN ALL CAPS and a few that are just not that great at spelling or grammar. The visit note is signed by me, and anything that they write will appear in the document. They rarely have to do narratives, but I never hesitate to give feedback when I need to, because I can't expect them to do a good job if they aren't given the training and feedback to do so. I am also able to edit anything they write as a narrative, so if it is just some minor spelling or grammar stuff I correct it quietly because ain't nobody got time to worry about that.

PCTs didn't go to nursing school and it's not fair to them to expect a good note if no one ever took the time to teach them. It's no different than any of the other skill. I remember the first time I was faced with PACU charting as a new grad. I had no idea what the heck I was supposed to do with that trifolded nightmare. Thank goodness I got feedback on my work, or i'd probably still be printing out pulse ox tracings and taping them to the ECG spot!

[Hygiene Queen]

I like to encourage newbies to just read through the charts and get an idea of what a good note looks like. That's how I learned, but I think back on some of my early notes as a new PCT... They weren't the worst but they sure weren't polished, either. I'm sure I induced a few snickers here and there.

The worst note I ever read came from a PCT who charted, "the patient pooped his pants"

[MunoRN, RN]

PCT's aren't nurses and aren't trained in nurse-speak, so it's unreasonable to expect that of them. What's expected is that they write down what they are seeing in plain english and in laymen's terminology, which is exactly what the PCT in the example did. I think to reprimand them for doing exactly what's asked of them would be what's unprofessional in the scenario.

[Alex_RN, BSN]

I think your facility needs to clarify what sort of charting is expected and useful. My facility does not and I got some excellent and logical tips from my co-workers.

[milliemm35]

I used to find these grammar and spelling mistakes distracting until I realized that the ones who were making them spoke accented English. It is not always obvious but for many ESL nurses charting is a very stressful task as they literally agonize over every word they write. I work with a lot of Asian RNs and I barely understand their English. As you can imagine their documentation is riddled with mistakes too. I once pointed out a simple error to one of the nurses , she became quite mortified , it actually made me feel bad. I think if the work they do is great so be it. MDs chart like madmen too, straight up computer code.

[djh123]

One of the things I used to see somewhat often when we were still doing paper charting (yeah - not even very long ago) that I thought was funny was someone starting their nursing note with 'Resident found in bed' or something like that. It always sounded to me like 'We had no idea where Mary was, but then voila! There she was! In her bed!".

[RNdynamic]

I work on a busy cardiac floor and most of our PCT's don't make hourly observations in the EHR. However we have one who does and it is riddled with spelling and grammar errors. It also doesn't include what I perceive as important information that needs to be charted. For example "patient sitting in chair eating a piece of candy, does not like what is on TV and says the hospital food is gross ". Is this something that should be corrected or is it just a matter of opinion on what is good vs. Bad documentation.

Sounds like she's just journaling the day as she sees it. I see nothing wrong with it. Maybe it helps her process the days events.

[klone, MSN, RN]

Sounds like she's just journaling the day as she sees it. I see nothing wrong with it. Maybe it helps her process the days events.

A patient's chart is a legal document. If she needs to process the day's events, she should use a blog, not the patient's chart. One does not JOURNAL in a legal document.