Jacqueline Vance, RNC, CDONA/LTC

So, have you ever realized that when you go to look at nurses’ notes in the medical record that you are making the same face you make when opening the door to a public restroom stall? Because you never know what you’re going to find in there. Scary right?

So forgive me if I rant a bit, but, nurses, do you read what you just wrote before signing and closing it out? Now, I am not talking about spelling or grammar. I wouldn’t have a job without spell check and grammar only counts with certain sentences. Like, “Let’s eat Grandma,” versus, “Let’s eat, Grandma.”  Then and only then is grammar a matter of life and death.

But I am talking about the content, people! The bane of any nurse leader’s existence is reading these notes and just praying a surveyor or lawyer never finds them. Stuff like, “Patient found on floor in pool of blood.” Really a pool? How do you quantify that? Is it a quarter size, an ounce or what? I mean, how much is it, because a plaintiff’s attorney is going to see dollar signs with that one.

This refers to one that was very early in my career and I still can’t let it go. It turns out the resident fell and got a nose bleed. So it wasn’t that much at all — no break of the nose, no change in hemoglobin or hematocrit. But that nurse felt that her documentation was fine. Could not see the problem. Oh … my … goodness.

Then there are the “soap opera” notes, as I call them. Where the nurse writes everything that is not important but does not tell us anything of clinical significance. Something like this, “Resident returned to facility at 7 p.m. via stretcher accompanied by two EMTs. Her brother was eating her lunch and this writer told her brother he should not be eating her lunch and he said she didn’t want it. This writer asked the resident and she said she wasn’t hungry so this writer said it was OK.”

OMG! Where is the assessment? Why was she in the hospital (diagnosis)? Where are the vitals? Give me some info, woman, for the love of all that is good and right!

OK, just breathe, Jackie. The point is, make your nurses read what they write. Offer a “learning opportunity” of what risk their documentation exposes them to. It can only help all involved.

If there is a hell, I bet you have to read nurses notes for all eternity from those who haven’t been educated and managed!

Just keeping it real,

Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, Senior Director of Clinical Innovation and Education for Mission Health Communities, LLC and an APEX Award of Excellence winner for Blog Writing. Vance is a real-life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.