As often as I can, I try to for write you, my faithful and beloved readers, a blog post that pertains to our industry. I try with varied success to make it entertaining or at least interesting. If it is neither, then maybe it is written because it is something that you really need to know. Now, you may not like my sense of humor or you may be completely bored by my posts in which case I suggest that you make use of your browser’s back or delete button. But I at least try.
Field nurses, on the other hand, do not seem to care that I am bored to tears reading their documentation. Look at the following example:
There is nothing interesting about this documentation. All of this with the exception of the teaching to take frequent rest periods and to take Lasix as ordered was on the flow sheet of the nurse. I don’t care that the patient has bowel sounds in 4 quadrants. I am so NOT interested in even and unlabored respirations. Whoa, check out that amazing blood pressure! Yippee. The patient has the same pulses that are noted on the front of the visit note.
On the other hand, I know things that you don’t about this patient. I know that she is also on potassium and I would have been interested in seeing that the patient was taught about the reasons why she needed to take her potassium as ordered along with the diuretic therapy. Do you think if a patient keeled over due to low potassium that ‘taught to take Lasix as ordered’ will cover you in court?
Would that have been better than teaching a 94 year old patient with heart failure to avoid prolonged standing? I am somewhat younger and no one has to teach me that!
What does, ‘take Lasix as ordered’ mean? Again, I know things you don’t know. I know that the patient has exceptionally poor vision, is at extremely high risk for falls and relies upon a walker to navigate in her home. (You probably guessed that.) Maybe it would have been better to teach the patient that when she took Lasix, it would be a good idea to be near ‘the loo’ as we called it in Australia. Or if she had a bedside commode to make sure it was near to her after taking her Lasix to prevent falls.
Frankly, any good pharmacist will tell a patient how medications are to be taken. It is the sole advantage of the home health care nurse to assess the patient’s ability to comply in the home environment.
Chances are if you cannot get me interested in anything you write, it is highly likely that you won’t be paid in a financial audit. And that is the truth. I am very interested in payment considerations. So, tell me a story. Prevent a fall and subsequent broken hip in an elderly patient. Teach the patient something they can’t learn by reading Prevention Magazine or watching Television. Remember that there are people out there paid to read nursing notes who have a burning desire to deny payment to your agency and I assure you that they have no sense of humor.
If none of that concerns you, think of me. Yes, it is all about me. Amuse me.
And above all, DOCUMENT WHAT YOU TAUGHT.
That’s all I have to say? What say you?