Worried about my charting-poor choice of words?

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Specializes in Peds, Pre and post op.

So I discharged my patient home yesterday...he had a soft stool..I charted it as loose..I know this sounds silly but now Iam worried. Maybe I should have mentioned this to the discharging MD..I should have charted it as soft..now I worry that if the patient does come down with some sort of diarhea that is nosocomial I can be blamed fo rcharting s"loose stool" and not calling the MD...should I be worried? Man..sometimes I feel like I just can't do the right thing in nursing!!

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Hi there

when you say soft stool, what does that mean? if you are worried that the client is gonna get C-Diff then there is 2 things that need to be in place, was the client on anti-biotic therapy and if it was loose then the lab wouldnt even look at it for C-Diff, c-diff stool is watery, like when you put it inside a container it conforms to the shape of that container, if its ice cream consistency they will throw it out and not even test it

hope that made you feel somewhat better?

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Specializes in Peds, Pre and post op.

Hmmm..it might have conformed to the shape of the container? But it wasnt super loose...it did not smell like C-Diff though...did not look mucousy or have any blood..seemed not loose/soft enough to be C-Diff..pt was on antibiotics...I just wish I mentioned it before I sent him home :(I am still pretty worried!

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honestly most up to date journals will tell you clients are safer in their home anyway, if there is nothing that you could do for the client, like iv antibiotics or some sort of complex dressing then they are better off at home. yea you should have mentioned it but the odds are the MD would have still discharged him, hopefully all goes well and you're richer for the experience.

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FWIW a person on my floor tested positive for C-Diff and his stool was mostly formed...

Proof is in the pudding (You're welcome for that nasty nasty description!!!)

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FWIW a person on my floor tested positive for C-Diff and his stool was mostly formed...

Proof is in the pudding (You're welcome for that nasty nasty description!!!)

The actual quote is "The proof of the pudding is in the eating". And it should go well with things like consistency of poop matching ice cream.

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Specializes in Peds, PACU, ICU, ER, OB, MED-Surg,.

I think C-diff can come in all forms. You charted loose stool. The physician should be reviewing all documentation and speaking to the patient. If patient has C-diff they will know soon enough and return or be placed on flagyl. I think you are worrying for no good reason. Just being on ABX can cause loose stools without c-diff, the medications do not pick between good/bad bacteria they just wipe out the gut.

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that feeling of continual dread/fear, is haunting, isn't it?

many of us nurses feel we are screwed either way, and that is just so unfair.

still, i always chart what i know to be true...

and strongly believe that fudging (oops:grn:) our documentation, will be the ultimate demise of professional nursing.

besides, if i chart that a pt is running a low-grade temp, should i worry they'll turn septic?

absolutely not, since a low-grade temp could have many etiologies.

just chart what you see and know to be true.

nothing more, nothing less.

leslie

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Specializes in Peds, Pre and post op.

Thank you everyone! I just feel I should have mentioned it! I just think I am not used to sending patient's home anymore after being in the ICU!! I was floated to the floor and sent a whole bunch home! I guess it makes me nervous now! I always try to hope that everything will be ok! I guess I just feel like I should mention everything..but really I charted the stool thing..and also charted that I told the patient to notify his primary MD of any diarrhea /watery stool upon discharge ect ect...

I agree with you leslie! I saw a pt the other night..nurse charted his temp at 97 ..then 97.4 4 hours later and them PM shift picked him up 4 hours after he was "97" well...per rectal temp and forehead temp he was...get this 89.5?! Ummmm..yeah if something is abnormal you chart it and do something!!! Not just pretend everything is OK!! My chart yesterday for the entire previous shift showed pts pupils 3mm brisk bilat..hello...one eye had surgery and is completelty non reactive!! Fortunately for me pt is alert and told me about his non reactive pupil...guess who would have had to take him to CT had he not been able to tell me that!:confused:

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Specializes in LTC, Psych, Hospice.
FWIW a person on my floor tested positive for C-Diff and his stool was mostly formed...

Proof is in the pudding (You're welcome for that nasty nasty description!!!)

Thanks for the visual that is now burned in my brain! :redpinkhe

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I am a new nurse and think some things that we document are sometimes subjective and worry that my clinical judgement on what and when to document should be done! What exactly is over or under documenting. In nursing school we learn to document every little detail of everythings. I always ask questions but I do notice people do document differently. I sometimes think about little details that probley don't matter at all. Thankfully, I have a wonderful preceptor and coworkers helping me find my nursing way. I just want to do what's right so that makes my anxiety go up without the experience and confidence as more seasoned nurse has I'm always thinking how could I have done my day and care better. My skills are getting better and more comfortable so hopefully my comfort will get better with documentation as well! I want to be confident but not over confident! :redbeathe

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Specializes in ED, ICU, Education.

I believe you have up to 48 hours if you feel the need to addend your nursing notes.

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