stupid documentation!

7 excuse me while i rant.................. i work in a ltc facility with a few nurses who just drive me crazy with their documentation!!!! (we have electronic medical records) i remind them nicely that the nurses notes are part of the medical record and to please use some common sense when documentating. here are a few examples for your amusement:

1. pt complained she had stroke. tested by giving glass of water to see if patient could swallow. water swallowed. no more complaints.

2. pt c/o chest pain and says that day nurse couldn't decide if she had a heart attact. no signs of heart attact noted. (nurse actually spelled heart attack as 'heart attact')

3. pt were up in hallway when he fof. too cnas at side. no injuries.

4. foley cateter were in place at beginning at shift. found pipe on floor. dr informed.


***by the way, the "day nurse" that #2 was referring to was me! talk about ****** off! i confronted the nurse and reminded her the patient has dx of dementia, and even if she said that - why the he** would you put it in the record????? of course i didn't tell the patient that non-sense. anyway, it's really not funny..................but these were the main ones that came to mind when writing this post.

whatever happened to objective charting? assessments? "no injuries" is way to vague, how about: moves all extremities, has full rom, etc..

anybody got anymore to contribute????
Don't use Med dx in note unless as a quote from a patient. For CVA: Pt c/o left arm weakness and decreased sensation. Equal mobility, grip strength, etc noted...Blah, Blah, Blah. Someone needs to do some education with the staff. The poor notes will get them in trouble with DOH or other legal entities. Do you have some policy on documentation to provide guidleines? Honestly, if the care for CVA and chest pain etc. really consists of what is in the note, they deserve to be in trouble.

Quote from imenid37don't use med dx in note unless as a quote from a patient. for cva: pt c/o left arm weakness and decreased sensation. equal mobility, grip strength, etc noted...blah, blah, blah. someone needs to do some education with the staff. the poor notes will get them in trouble with doh or other legal entities. do you have some policy on documentation to provide guidleines? honestly, if the care for cva and chest pain etc. really consists of what is in the note, they deserve to be in trouble.

That is some of the worst documentation I have ever read. It tells me nothing, yet it opens a whole Pandora's box of possibilities. Misspellings aside, it contains nothing of value to anyone who would read it afterward. They are just notes for the sake of notes. I wouldn't want to have to go to court with only this to back me up.

A heart attact. Really? REALLY?And the DON saw nothing wrong with that particular piece of, er, documentation? You may love your place of employment but either you need to take your concerns to the DON and the staff educator (if you have one---maybe he/she will listen) or start to dust off your resume. This kind of nonsense could cost you your license if there was a lawsuit or get all of you in a spot of trouble if the state surveyors see it. 2. Pt c/o chest pain and says that day nurse couldn't decide if she had a heart attact. No signs of heart attact noted. (nurse actually spelled heart attack as 'heart attact')

In the facility where I am employed, charting is reviewed on a daily basis by the ADON, as the info presented @ morning report is drawn from the previous 24 hours' charting.

what kind of "nurse" is charting as described above?

wow, scoochy, that's a fantastic idea for the adon to review the documentation. actually, we don't have an adon at the moment. i have informed my don i am interested in the job and just waiting to hear. hopefully, i will get the position and be able to provide better & more education on documentation. i also would love to make a few other changes.......

Quote from nc29momwow, scoochy, that's a fantastic idea for the adon to review the documentation. actually, we don't have an adon at the moment. i have informed my don i am interested in the job and just waiting to hear. hopefully, i will get the position and be able to provide better & more education on documentation. i also would love to make a few other changes.......

Let me tell you....if you ever get called for a deposition on that charting...you are hosed. I've been called x2 and had to read other people's stupid stuff and the other attorney just fed off of it. You DON needs to step up to the plate!

Is your "DON" literate and/or competent?Why not look for a job where coworkers are higher functioning?

wow that's horribly irresponsible! Where is your DON? Ours would send those right back and tell us to delete them or make corrections. We aren't allowed to be subjective, in fact no one is. I'd hate to see those nurses in front of a smart a$$ lawyer!

Bad documentation coupled with horrible use of tenses and spelling. We should always try to draw a picture with our documentations I've been told. It does not have to be overly wordy but just enough to give the next person what there is to know.Yes, this may open a can of worms, but what title do these nurses hold? Sometimes people do things because they know no better or that is where their knowledge begins...(or ends). Not that that is much of an excuse though...