Skip to content

Posts tagged ‘Nursing Documentation’

You Do the Charting!

photo (24)

2013 is the year we quit talking and start doing.   If you are bold enough. you could be the proud owner of a Haydel Consulting Services flash drive.  Be the envy of your friends with this ultra sophisticated, data base storage device that has been proven secure and reliable and goes where you go.  Better than a cloud drive, the HCS drive doesn’t rain, snow or block your sunshine.  Mobile storage for mobile nurses!  All you have to do is attempt the documentation challenge presented below and enter your response in the comments section.

Challenge:  Consider the following information and write a brief but thorough narrative describing your care.  Your vital signs and assessment are performed and documented.

You are on call on a Saturday evening when a physician calls you about a patient.  You have never seen this patient but open up your computer and see that the patient is a 78 year old female with diabetes.  Secondary diagnoses include congestive heart failure, kidney disease and Alzheimer’s Disease.

The physician is concerned because the patient’s daughter called and said her mother was ‘acting out really bad’.  He wants a blood sugar and lab done to ensure her lytes are in range.  He also wants to know if she may be hypoxic and asks you to weigh the patient and get a pulse ox reading.

Your assessment is unremarkable.  Her fingerstick blood sugar after supper was 162.  Her pulse ox is 99 and her weight is recorded at one pound less than the prior week.  Vitals are good and the patient appears to be in her usual state of health other than the behavioral disturbances.  You ask the daughter what prompted her to call the MD and she reported that her Mother did fine all day.  She was confused but pleasant and content.  Her mother listened to music and folded a laundry basket of dish towels while the daughter cooked for a family gathering later in the week.

At about 6:30, the patient began showing signs of agitation.  Nothing seemed to work to quiet her anxiety.  The daughter gave her some xanax as ordered and tried to reason with her mother.   Twice the daughter had to go outside and bring her mother back indoors.  The daughter is genuinely afraid she will have to put her mother in a home.

So, you’ve drawn the lab and performed the assessment.  What else might help this patient and her daughter?  How do you document it?

The winner will be announced a week from Friday.  That means that if you have case conference or staff meeting between now and then, you can all practice ten days in a row.  There is no limit to the number of entries but they all must be original.  The grand prize will be chosen from all entries so it really doesn’t matter if you can’t chart a skill to save your life.  You can still win and after next Friday, you will know how to document at least one skill.

Amuse Me!

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:

Actual Document

I can't make this stuff up.

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.


That’s all I have to say?  What say you?

%d bloggers like this: