i work as a psw (cna) in home health. in my psw classes we did touch on charting but not in any great depth and i haven't learned anything about charting yet in ns. anyway, i have a clt whose bum crack is red and has a nickle sized sore between the cheeks. the first time i had a clt with a sore on the bum i did chart using similar words to what i just wrote. how unprofessional!! i left that clt's home feeling very embarrassed because i was unsure of how to describe it on paper. this time i charted; clt c/o sore buttocks. psw observed crease of clt's buttocks red with nickle sized sore in crease. though the wording is better, i'm still unsure of how to chart something about the inside of someone's bum!! please help!! next time i want to be able to sound like a professional. i know i will learn proper charting eventually, but i'd still like to do it properly as a psw.
thanks in advance for any tips!!!:heartbeat