Is it just me, or is nursing documentation lacking something? I mean, I don’t expect a nurse to write a book, but I don’t want to play Sherlock Holmes when I am trying to read a nurse’s notes, either.
I’m like, wait: The resident is in the hospital so what happened? I don’t think the hospital fairy somehow swooped in and picked them up! I’m talking about major gaps in documentation. Yeah, I get it, we’re all super busy. But we need to have an idea of what occurred. My motto: Just document what happened, what you did about it and what the results were. Simple as pie. Or it should be.
But I get it, I’m a mom. I text my kids a long message and I get an emoji of some kind back. (I pushed your nine pounds out of my body and all I get is an emoji? I won’t even get into the happy birthday texts.)
Oh my gosh, what if nurses start using emojis to document. Could you just imagine?
For example, what if we saw this:
It would mean: Newly admitted resident with vomiting and diarrhea, c/o a headache.
Or we see this:
And it means “Resident with signs and symptoms of anxiety and depression.”
Or we have this:
Why that’s “Resident returned from dental consult for tooth extraction noted with swelling. Resident c/o pain. Medicated for pain. Will monitor”
Or we have this:
That would be: “Resident noted on rounds to be unresponsive. Vital signs unable to be obtained.”
And this would be me going, “Noooooooooooooooooooooo! I already can’t handle these notes as they are!”
Just keeping it real (Well, hopefully not!),
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