Using Creative Charting...

10 Just wondering if there is anything that you have ever "creatively charted"? I had a pt awhile ago who had a SBO and had a projectile emesis. My charting went something like this... Pt had approx 500cc brown emesis, 200cc of which was collected in the emesis bag and the rest was distributed throughout the room". My coworker heard me chuckle as I was charting... I had to share!
I did have a coworker who was a clinical instructor in nursing school and her student had to document wound information.Using the word "butt crack" as a location looks awkward in print, we looked up the proper anatomical term for that area.

Could you use glueteal fold? Just wondering!

I thought the gluteal fold was the curve between the butt and the thigh???

So did I. I use "gluteal cleft" or "cleft of the buttocks" to describe that particular part of the human anatomy.

You are correct. How about glueteal cleft???

I use the term glueteal cleft when describing an abnormality of that area! So far, I haven't been told by my higher ups not to!!One time I was tempted to chart a code brown that was epic in amount as a "Poo-poo tsunami". I instead charted about the amount and consistency of said event.

"perianal region"?i had a patient once with a terrible skin condition that caused all of her skin to weep copious amounts of serum constantly. we had her on a pressure-relieving surface for her discomfort but it was just dripping off the sides of the bed to the floor, drip, drip, drip constantly. i charted that it saturated two bath blankets on the floor about every four hours. unconventional but accurate-- no real way to measure it, though i suppose we could have weighed the blankets dry and wet. sorta didn't matter.

[color=#b22222]where i work....it's referred to as the "natal cleft"

i had a pt. a year ago that came in with priapism, and i charted the following... "persistent hard on"

I worked for an eating disorders facility for awhile. The medical director was known for interesting charting. He wrote about "gravitationally challenged" patients sometimes.

That's one I'd like to use for my frequent fallers!!!

I have been worried that with the introduction of computer charting, the medical record was becoming a bland boring document consisting entirely of objective facts and figures with no indication whatsoever of the unique circumstances of each event or of the personality of the patient and those caring for him/her. I love the richness of words and the nuances that can be conveyed in a couple of phrases so the OP's entry in the patient's chart makes me very happy!