Using medical terminology as a nurse

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Hi guys, so I’m a new LVN/LPN.. I did a COC on one of my patients d/t having blood in her urine. My DON just informed me that I wasn’t allowed to use the word “Hematuria” because I’m not a doctor or NP so I’m not allowed to “diagnose”. Is that true? I thought Hematuria just meant blood in urine. Didn’t know it was a diagnosis. Hope you guys can clear this up for me. Because I have been using the word Hematuria for a lot of my charting esp the ones on monitoring for UTI. Thank you!

I would have, always do, and will continue to chart hematuria when I see it. It to start with is NOT a diagnosis as previously pointed out and you could I guess write

Self voided 250mls urine. Rose color. No clots ? Hematuria.

Then await further testing i.e your dip.

Simple as that. You did nothing wrong

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Specializes in Emergency.
On 7/26/2019 at 9:27 PM, Crash_Cart said:

Did a urine strip record and confirm a high presence of RBC's in the urine?

I mean how do you know it's Hematuria and not something else like the beets they had for lunch?

Next time I go in for a physical I plan to eat a ton of beets and asparagus the night before. It will be hilarious! (Kidding, I won't)

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On 7/28/2019 at 6:02 AM, Nurse Beth said:

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.

This crossed my mind as well. I can see the documentation now, "right lower leg missing and remaining end of leg draining copious amounts of liquid red stuff". LOL.

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2 hours ago, CKPM2RN said:
2 hours ago, Forest2 said:

This crossed my mind as well. I can see the documentation now, "right lower leg missing and remaining end of leg draining copious amounts of liquid red stuff". LOL.

Ah ha ha ha ha I love these ideas!

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I worked for an agency where they said we weren’t allowed to say the patient was sleeping.

We *could* say the patient had their eyes closed and was breathing quietly.

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12 hours ago, Daisy Joyce said:

I worked for an agency where they said we weren’t allowed to say the patient was sleeping.

We *could* say the patient had their eyes closed and was breathing quietly.

Ugh......the neverending debate over what can you chart at night. How many ways can you write it. Lol. I continue to write what I have always written.

2am. Patient appears to be asleep. No clinical concerns to report at this time.

I keep my charting super short ?

This I have written for 20 years. Have yet to have a problem. I say yet!

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"Hematuria" is not a diagnosis. It is a symptom. Blood in urine is a symptom of whatever condition is causing blood in the urine. Your DON needs to go back to clinical practice for a couple of years to learn what correct clinical practice is. It sounds to me like the DON didn't want any notation of hematuria or blood in the urine in the patient's medical record, because that would raise eyebrows with the state if it was not addressed promptly (or at all). (I am assuming this occurred in a LTC facility.). Did you ask the DON what you should write instead of hematuria? Most LTC facilities don't want to address any medical issues because they don't want to lose money. If a patient had blood in their urine, the LTC facility would have to collect a urine specimen to be sent out to a lab, get the results back and possibly send the patient out to a urologist or to the emergency room to get a diagnosis & treatment, which could possibly affect their profits.

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Specializes in Critical Care.

How do you know it's blood?

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On 7/27/2019 at 7:04 PM, Crash_Cart said:

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?

If the patient is on a medication such as Rifampin, and no blood, then the urine would be clear with a red tinge, but if there is blood present then there may be clots.

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42 minutes ago, fibroblast said:

If the patient is on a medication such as Rifampin, and no blood, then the urine would be clear with a red tinge, but if there is blood present then there may be clots.

This is why you must always document

Urine red, ? Hematuria, await further testing. Or just document nothing at all until you have strip tested it. But there is nothing wrong with writing ? Hematuria.

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Specializes in Short Term/Skilled.
On 7/30/2019 at 7:55 PM, Daisy Joyce said:

I worked for an agency where they said we weren’t allowed to say the patient was sleeping.

We *could* say the patient had their eyes closed and was breathing quietly.

This is how I document. I don't assume anything, I just write what i see. I mean, I really don't *know* if they're sleeping, they could be "resting their eyes". I know - I'm neurotic but this is how I was taught.

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Oh yes, a very large crock of poop is usually involved here .

Staff all say the patient seems to be sleeping comfortably, but the patient claims no, I never draw a relaxed breath in 8 hours. I am awake all night.

Sleep study, otherwise I am not even slightly interested in your subjective and baloney problem.

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