Dear RN,
Example of documentation about Refusing Interventions
Declines IV antibiotics and renal ultrasound. Educated on the importance of antibiotics and diagnostic imaging for proper care and evaluation.
Patient verbalizes understanding of risks and benefits but continues to decline. Alert and oriented x4, speaking clearly.
Made aware he can reconsider at any time. Vital signs are stable, see flowsheets. Provider made aware of patientโs refusal.
Itโs not enough just to say patient refused medication.
Document to prevent any liabilities
Cheers ๐ฅ
PROTEST BY NURSING STUDENTS OF TARABA STATE COLLEGE OF NURSING JALINGO AGAINST THEFT AND RAPE CASES AT THE SCHOOL HOSTEL DUE TO INADEQUATE SECURITY ๐๐ฅต๐ช๐คฆ
A 19yr old female students allegedly raped by 8 robbers in the female hostel????? What the hell ๐ฅถ๐ฅน๐
Dear RN,
Stop writing โpatient stable.โ
That phrase is too vague for nursing documentation. Chart the assessment findings that show the patient is stable,not just the conclusion.
Vague:
Patient stable.
Stronger documentation:
Patient is awake, alert, and oriented ร4. Vital signs: BP 128/74 mmHg, HR 78 bpm, RR 16/min, SpOโ 97% on room air, temperature 36.8ยฐC. Respirations even and unlabored, with no use of accessory muscles. Patient denies chest pain, shortness of breath, dizziness, or discomfort. No grimacing, guarding, diaphoresis, or restlessness observed. Call bell placed within reach on the patientโs right side. Patient demonstrated the ability to use the call bell and was instructed to call for assistance before getting out of bed.
Plan of care continues.
Remember: Donโt chart only your impression. Document what you see, hear, and measure,and what the patient reports.โโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโ
Cheers ๐ฅ
Dear RN,
Let me drop some Nuggets about documentation tonight.
AVOID CHARTING PHRASES LIKE:๐๐พ
โข โWill continue to monitor.โ
โข โPatient resting comfortably.โ
โข โPatient resting in bed with eyes closed.โ
โข โNo acute distress.โ
โข โStable.โ
โข โContinue treatment as ordered.โ
INSTEAD SAY:๐๐พ
โข Plan of care ongoing.
โข No new concerns at this time.
โข Patient observed resting in bed with eyes closed. Respirations even and unlabored. No distress noted.
โข Patient reassessed. Findings unchanged from previous assessment unless otherwise documented.โโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโโ
Remember that one day your chart may be audited
Cheers ๐ฅ
Hello Everyone,
Iโm Jane
I am a Registered Nurse
I sell skin care products
Unplug from your plug and plug here๐
If your vendor go low, I go lower!
Hereโs a link to my WhatsApp
https://t.co/zRVoha6Ycf
Itโs International Nurses Day, but for thousands of Nigerian nurses, itโs just another day of waiting.
Since May 2023, the NMCN has not signed or released any certificates. This has stalled career progression, limited job opportunities, and left young nurses in professional limbo.
Today is a reminder to the world that this delay is unacceptable.
Join our solidarity as we demand the immediate release of our certificates.
#releaseourcertificate
#nomoresilence