Using medical terminology as a nurse

klone, MSN, RN · Jul 27, 2019

No, it's not diagnosing to say "hematuria" but it's best to not use medical terminology when talking to patients. Most lay people would not know what "hematuria" means, and it's better to use simple language (many say you should use 5th grade level language). How about a simple "blood in your urine"?

Wait, I think I was mistaken - was this in charting, or in a conversation with patient. Agree with the others - you shouldn't call it hematuria or blood in the urine unless you have actually determined the presence of blood in the urine through a UA. Otherwise, I would describe it as "pink-tinged urine"

It's not problematic that you are an LVN calling it "hematuria" if you have confirmed that it actually IS hematuria. It would be equally problematic if a physician or NP called it "hematuria" based only on appearance, without an actual UA confirming RBCs

Crash_Cart · Jul 28, 2019

28 minutes ago, RCHCLVN said:
Ahhh you’re right. So in that case we would document that urine was red in color?

Think about it this way. If you chart the pt. has Hematuria and a regent test strip, or urinalysis result later reveals that's not actually the case, then have you made a documentation error on the patient record?

Article:

"Nurses chart urine color by reporting what they observe without making inferences, explains the Chronicle of Nursing."

https://www.reference.com/science/nurses-chart-urine-color-3ad77a09226b027c

Jory, MSN, APRN, CNM · Jul 28, 2019

Gross hematuria (blood you can see in urine) is the correct term. That isn't a diagnosis anymore than bleeding from anywhere else.

Otherwise chart what was found on the strip, "positive for blood", etc.

If she is still calling gross hematuria a medical diagnosis, she's wrong.

Glycerine82, LPN · Jul 28, 2019

I'll document hematuria once they've been dx with it. Otherwise I just describe the color and clarity of the urine.

JKL33 · Jul 28, 2019

10 hours ago, egg122 NP said:
Patient care related decision making is not being changed but not using the word hematuria. If I received a call stating the patient's urine is red, the urine is bloody, or it looks like there is blood in the urine, it would lead to the same orders being issued as if the person stated that the patient has hematuria.

You misunderstood that portion of my comment. I did not say that your (provider) decision making would be changed; I disagreed with you that when the OP has been given questionable information about his/her scope of practice that s/he should then change his/her documentation practices because of that.

[However, with regard to blood/bloody, though, that doesn't solve the issue Crash_Cart raised and doesn't help the overall issue the OP asked about. If s/he can't say hematuria because that is diagnosing, why would s/he be able to diagnose "blood" in the urine or use the word "blood," either?]

10 hours ago, egg122 NP said:
I feel this is not a hill to die on with an employer

I have never had a calm and rational rebuttal lead to my figurative death or disadvantage or termination. So that's the tack I take. Discussion. "I'm not sure I understand it that way; can we look into this further?" That sort of thing. I don't just up and change the way I do things because someone said something.

I guess regardless of our personal feelings about this, the OP has done the right thing by seeking to verfiy the information given by the DON.

JKL33 · Jul 28, 2019

53 minutes ago, Glycerine82 said:
I'll document hematuria once they've been dx with it.

What if they did have confirmed hematuria, but they ate a metric ton of beets around the same time the hematuria cleared up?

? Sorry.....just kidding. Your way is good.

Career Columnist / Author · Jul 28, 2019

Hopefully while working under your DON none of your patients ever scrapes their skin or has a cut with dripping red fluid. We'll have to start a new thread.

K+MgSO4, BSN · Jul 28, 2019

The reason I was being pedantic was I recently got an admission of a patient who was reporting malena. Not witnessed in ED and no blood work done based on "symptoms " i.e. pt felt woozy after each episode and the very sleepy consultant accepted the admission over the phone.

Pt admitted to the ward. Bloods done no HB drop, no urea rise. Digging into his history had eaten beetroot soup that day and "faints" at the sight of "blood".

Prompt discharge, suggesting not to eat beetroot or at least don't stress with the bowel actions. Conversation with the consultant about asking for basic bloods despite the story. Made him talk to the AO in ED regarding the same.

Its about getting all the information before jumping to a diagnosis.

Oldmahubbard · Jul 28, 2019

I am a postmenopausal NP. When I noticed lady partsl bleeding last year, I quickly made an appointment with my GYN.

I had this problem before, and knew the routine about ultrasound and biopsy.

In the meanwhile, I kept working as usual, even though I soaked through a tampon every hour.

But I was a little surprised when I was told to come to the GYN office to see the NP there.

Apparently they wanted to be certain the blood wasn't actually coming from the bladder.

Hhmm. My insurance was billed for this.

When I was told I was being checked for "hematuria", I said "I must be in the wrong orifice"

OK corny joke of the day.

My advice : If your employer complains, don't use the word hematuria.

BSN-to-MSN, ADN, BSN, RN · Jul 28, 2019

Hematuria is a symptom, not a diagnosis. That is some neurotic DON.

silverbat · Jul 28, 2019

When I worked with a Urologist he wanted to see documentation such as “ urine is bright cherry red in color, is tea colored, is light pink in color, thick red clots noted in urine. Etc.

Lipoma, BSN, RN · Jul 30, 2019

I charte hematuria alllll the time in my documentation. It's actually one of our options to click on our genito-urinary chief complaints in our EMR.