Words not to put in a patient chart

[Sapphire Silk]

This is a Sighthing. One of my students told me today about a "staff huddle" regarding the proper terminology to use when describing nasty infection drainage: purulent, in case anyone is wondering.

One should not use the word pussy, especially when describing the purulent drainage from an abscessed labia.

[catcul]

This is a Sighthing. One of my students told me today about a "staff huddle" regarding the proper terminology to use when describing nasty infection drainage: purulent, in case anyone is wondering.

One should not use the word pussy, especially when describing the purulent drainage from an abscessed labia.

It's important to use correct terminology when communicating with colleagues. For some reason, I have a bad mental image about this.

An abscessed labia sounds incredibly painful. I thought having an abscess on my finger was bad.

[Kaylyn]

Heh, the terminology was technically correct. Just...unfortunate wording. "Pussy discharge", in this particular instance, would be correct either way you choose to look at it...

I'll...just be over here in the gutter. *coughs*

[Deserted]

Heh, the terminology was technically correct. Just...unfortunate wording. "Pussy discharge", in this particular instance, would be correct either way you choose to look at it...

I'll...just be over here in the gutter. *coughs*

Leave me some room.

[Hermione]

I've seen some odd stuff in notes, but never that. LOL

On a more serious note:
As a coder I believe 3 things about documentation:
1. Never put anything in a note you wouldn't want read out loud in open court (this applies more to psychiatry, but all disciplines would be wise to remember this).
2. Never put anything in a note that would be inappropriate for an auditor to see (personal opinions, etc..if a patient is upset, say they're upset...if you have to answer the same question several times, say you had to answer the same question several times).
3. Never put anything in a note you wouldn't want a patient to see.

Always stick to the facts, with CORRECT medical terminology. Anything not medical terminology the patient tells you should be in quotation marks in the Review of Systems and noted that it is per patient report.

"Purulent" or "pus-filled" would be preferable here, indeed.

Keeps, you know, minds out of the gutter and me from doing a double take when I have to read the note. #justsayin'

Sapphire Silk, do you agree?

[mathnerd]

Leave me some room.

It's getting crowded in here again. Do I need to go on another beer run?

[Sapphire Silk]

I've seen some odd stuff in notes, but never that. LOL

On a more serious note:
As a coder I believe 3 things about documentation:
1. Never put anything in a note you wouldn't want read out loud in open court (this applies more to psychiatry, but all disciplines would be wise to remember this).
2. Never put anything in a note that would be inappropriate for an auditor to see (personal opinions, etc..if a patient is upset, say they're upset...if you have to answer the same question several times, say you had to answer the same question several times).
3. Never put anything in a note you wouldn't want a patient to see.

Always stick to the facts, with CORRECT medical terminology. Anything not medical terminology the patient tells you should be in quotation marks in the Review of Systems and noted that it is per patient report.

"Purulent" or "pus-filled" would be preferable here, indeed.

Keeps, you know, minds out of the gutter and me from doing a double take when I have to read the note. #justsayin'

Sapphire Silk, do you agree?

Oh absolutely! In fact, your advice is routinely taught to both nursing and medical students, who promptly forget and fill charts with all kinds of stuff they shouldn't. I do legal nurse consulting on the side; you would not believe what I see people chart, or hear them say in deposition.

[Metody]

I keep it extremely detached and professional, except for when quoting patients. I give people lots of leeway for pain and dementia, but if someone becomes threatening to self or others, is racist, sexual, or just plain obnoxious when they're fully oriented, I am quite happy to transcribe what they say.

Some of these patients, I dream of being able to quote them in court.

[crazylegs]

Then let me introduce you to my colleague who treated a patients gash on her, um...

[jedimaster91]

It's getting crowded in here again. Do I need to go on another beer run?

After the mental image of an abscessed labia....maybe something stronger.