Documentation – what were you thinking?!

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Over the years I have seen some hilarious notes made by nurses and physicians.  Some of them I can understand that it rushing though their notes or interruptions, but some just leave me a scratching my head in disbelief.

Here are a few examples:

1020:  Patient to eosaphagram??????

1220:  Patient suddenly reappeared in room.

1005:  Pt NPO per MD orders.  Patient given PO meds with 120 cc of water.  Pt remains NPO.

1504:  Patient given 2mg Morphine IVP though that beautiful foot IV.

The sad part about this is…..these are all from the same nurse.  Imagine the stuff that was documented that I did not see!

What I am trying to say is that your documentation is a direct reflection of you.  It shows what you did and why, and can also give a little insite to you thought process while you were caring for that patient.

It not only looks bad to your manager and co-workers, but to a lawyer, this stuff is like gold.  It looks like this nurse was a moron.  Patient suddenly reappeared??????  Do you mean they weren’t in their room and then there was puff of smoke and BAM….there they were?  Did you have an order to give the PO meds while the patient was NPO?  Beautiful foot IV?

Your documentation tells the story of your care for that patient and the events surrounding that patient while they were under your care.  It can show a lawyer and jury if you provided the appropriate level of care for the patient or not.  I can show if you are competent as a nurse, or at the very least competent at documentation.  I would rather it show that I provided the appropriate care and that I actually know what I am doing.

Think about things before you write them.  When I was a new grad on orientation, my preceptor made me write everything out, then review it before I actually wrote it in the chart, for this very reason.

12:10:  Nurse Manager completed his blog and suddenly disappeared.