Documentation: What you need to know!. Kindred Hospital Louisville Shannon Ash, RN, BSN. Sometimes documentation is funny. Or just doesn’t quite come out right!. “ Patient has chest pains if she lies on her left side for over a year.”
Kindred Hospital Louisville
Shannon Ash, RN, BSN
Did the person who charted this witness the event, assume that what is described is what happened, or did the patient report that it happened this way?
This type can make the information unclear. If this was witnessed, it is better to say “Witnessed patient sliding to end of chair and chair flipping over on top of patient. Tried to prevent patient from sliding out, but was unable to reach patient in time.”
This charting tells us much more clearly what happened. It’s obvious the caregiver didn’t see the patient pull the tube out, but documented subjectively what happened.
Don’t forget that any situation like the two described on these pages also warrants an event report to be filled out completely.
The above note describes Hydromorphone being given IV x 2, not something within the scope of practice by an LPN. This charting could leave it open to interpretation that this person gave the meds. If it was given by someone else, THEY should chart it.
This sounds bad to everyone who reads it. Chart what you did (i.e., gave the medication, and rescheduled the lab draw).
Make an event report if a medication error is made - and not giving a medication at the appropriate time IS a medication error.
This note would have been fine if it weren’t for the line with the extreme use of exclamation points. The tone of the note is blatantly critical.
Report factually what happened. Not emotionally.
Talking about Michelle and Buffy is fine if you guys are hanging out. Documenting “Michelle” and “Buffy” is not appropriate in a patient’s chart.
Don’t chart the same thing on every patient every day!
If the patient is resting in bed quietly, great, but that shouldn’t be the ONLY thing you chart.
Never use slang or profanity.
Don’t criticize or make judgements about care other care that is done.
If your professional opinion is that the care ordered isn’t the most appropriate - inform a supervisor immediately.Important Documentation Tips