ADVICE, P. R. N.

Nursing, Apr 2004

DOCUMENTATION

Getting a leg up on charting

I'm a recent graduate. Last week, I made the following entry into my patient's chart: Patient has good pedal pulses and moves legs and feet well. My nurse-manager told me this entry wasn't specific enough, but she didn't explain. I'd like to improve my charting skills. Can you help?-J.S., TENN.

Many new nurses make the mistake of charting subjective, rather than objective or factual, information. Subjective information, such as patient has good pedal pulses, might be questioned in court because it reflects your opinion about a patient's condition, not your objective observations.

That's not to say that your patient's subjective statements are off-limits. You should include pertinent observations and information he provides about his own condition. For example, "My foot hurts" is a subjective comment you'd want to chart-and follow up on.

To turn that subjective charting entry into an objective one, you might write the following: Dorsalis pedis and posterior tibial pulses in legs 2 /4 bilaterally. Leg strength 5/5 bilaterally for all major muscle groups. Sensation intact to light touch; pt. denies pain, numbness, or tingling. Shin warm and dry. No edema. Besides sticking to the facts, this entry shows anyone who reads the chart that you assessed the patient's legs and feet thoroughly.

Discuss your desire to improve your documentation skills with your manager and ask for her feedback. Brush up by reviewing some of the many books and Web sites available on nursing documentation. Also review any guidelines your hospital provides.

PREVENTING ERRORS

Idle talk

I admire colleagues who can multitask, but one of the nurses in my unit has gone too far. She charts, draws up medications, and performs many other tasks while talking to other staffers. One of these days she's going to make a serious error-or distract another nurse to the point that he makes a mistake. How can we get her to clam up without hurting her feelings?-J.V., FLA.

Take the direct approach. Tactfully share your observations with her and tell her you're worried that her scattered manner will lead to an error. If she involves you in conversation while you're performing a nursing task, cut her short and remind her that what you're doing requires your full attention. Encourage others on staff to do the same.

What if she continues with her distracting behavior? Alert your nurse-manager to the issue so she can step in and talk with this nurse about the importance of concentrating on her work to prevent errors.

Don't worry so much about "hurting her feelings." Among professionals, patient safety always trumps personal feelings.

IMPAIRED PARENT

Unsafe at any speed

I work in a pediatric clinic in a suburban area where most patients arrive by car. Twice recently I've cared for a child brought in by a parent who reeked of alcohol. In both cases, the parent had driven the child to the clinic for treatment-and drove the child away afterward. What should I do in a situation like this?-C.L., N.C.

Not only do you have an ethical and legal obligation to protect your patient, but you also have an obligation to keep an intoxicated person from getting behind the wheel of a car and endangering public safety. In the situation you describe, you should tell the parent that you'll help her find other transportation home. If she becomes angry and refuses to accept your assistance, you'll have to call the police. An officer can give a sobriety test to the parent and determine if she's competent to drive. Don't try to make a judgment about whether she can drive safely yourself.

What if she decides to leave before the police arrive? You can't force her to stay against her will, but you can inform her that you'll give the police her license number and a description of her car and that they'll pick her up.

Child endangerment may fall under your state's child abuse statutes. In some jurisdictions, parents can be prosecuted for driving a child while legally drunk according to standards in that state.

Seek legal counsel on how to handle situations like the one you've described and work to develop a clear policy and procedure for all clinic staff to follow-including a plan for providing alternative transportation when necessary.