Proper Documentation

• Can you please give me your feedback about a debate we are having at work? I was doing a follow up note on an incident report for one of our patients that fell his injury was on his right eye and yet this other nurse was documenting his injury being on his left. The nurse responded that she was always taught to chart someone’s injury whether it be on the left or right by how she is looking at the patient. So looking at the patient face to face his injury is on her left( his right in reality). So she’s documenting the injury is on his left! Please tell me if I have been doing this wrong for the last 13 years.
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Um...no. why would you ever do that? Makes no sense at all.

There is no debate. The patient's left eye is always going to be the patient's left eye.

She just dont want to admit that she assessed the patient wrong.

Anatomical position. First thing you learn in A&P. Was she asleep that day?

It's the right side of HIS body. It should be documented as the right side. Try pointing it out this way to her: If a surgeon is going to amputate the right foot for a non-healing ulcer, what food should he amputate? The patients right foot, or the left foot because it's on the surgeons right?

No, you haven't. Your colleague has been though