![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
Nov. 29th, 2017 at 7:23 PM
~~
Here you are,
![[livejournal.com profile]](https://www.dreamwidth.org/img/external/lj-userinfo.gif){kind=small}
acelightning and browngirl~~
A condensed version of the discussion we have in class:
Why do we document?
-To communicate with other members of healthcare team
-To communicate with subsequent shifts
-Legal purposes
Documentation should be:
Factual
ConciseWithout unapproved abbreviations
(can tell you some good stories about those, if you'd like)
Formats:
Example of narrative note:
Hope this helps; feel free to ask for more details
Two videos below.
~~
Comments
55 years old female, status post left total hip replacement, post-operative day #1 (i.e., surgery was yesterdayZ), medicated for pain three times this 7a-7p shift according to the Dr's order for pain meds as necessary, and it helped. No other complaints, no acute distress. Left hip dressing dry and intact, hemovac (drain inserted in the surgical site, a tube connected to a bulb) is where it should be, moderate amount of bloody drainage in the bulb. Patient was out of bed to chair for 3 hours.
Hope this helps ;) D'you want the abbreviation stories and the med error stories?
And--well--the doctors write the orders. However, and this is what we teach, and emphasize--the nurse has autonomy and independent judgment. Just because the order is there, a nurse is not obligated to follow; in fact, if a nurse follows a definitely wrong order, s/he will be morally, ethically, _and legally_ responsible for it.
_Respondeat superior_ does not apply.
...there are stories about this concept, as well, if you're interested...
Shall have to write out some tales over winter break; will tag you when I post them.
Edited 2017-12-03 04:40 am (UTC)
here's a story from my archives, in the meantime
https://med-cat.livejournal.com/405290.html#cutid1
Re: here's a story from my archives, in the meantime
Re: here's a story from my archives, in the meantime
Re: here's a story from my archives, in the meantime
Re: here's a story from my archives, in the meantime
(love your icon)
Even common abbreviations can confuse at times
Yes, like "SOB"?
Have I told you the stories of
"PBBB"
"RLND"
and
"PWITSOF"
?
;)