-no evidence of mucus membrane.

While thinking what to write in my patient’s record, I decided to peruse the previous chartings made by my classmates in their respective shifts when I came across my own handwritten report of my client. Charting is the written document of the Nurse in the Patient’s Medical Record. It is where we write our observations and the follow up interventions to our client’s problems. A usual charting includes also the “subjective” data of the patient, which are usually verbalized complaints; Nursing Diagnosis; and the Nurse’s plan. But in this particular hospital, the SOP is to write only the “Objective” or observable data and the implemented interventions of the nurse. (Click here for my first ever REAL hospital chart [HYUUUCKKK!!!])

Yesterday, my Clinical Instructor asked me to rewrite my Nurse’s note. Thank goodness the previous chartings have already filled all the previous pages or I would not have been able to write in a clean leaf and would have left a page dotted with erasures accompanied each by my own signature. I really didn’t know what was the problem with my original charting, nevertheless, I did what he said. I rewrite the whole page as it was and passed it. This morning, Angelo told me that our CI was pissed off yesterday by Neil’s and my own charting. I asked him why and he said Neil and I made some terrible “technical’ mistakes… He was sure that it was with the spellings and other grammatical stuff. (I think Neil misspelled received as RecIeved in his patient chart.)

By Nine, as I read my own charting the other day I found this line;

-no evidence of mucus membrane.

HUH?!!! I mean, WHAAAAAAAATTTTTTTTTTTTT????!!!

I reread the line a couple of times and I was wrapped in a fog of an embarrassing disbelief. Who else read this record? Of course, my classmates from the other shift. Yes my Clinical Instructor. I looked at the bottom of the page and saw my own signature countersigned by my CI, then by the Staff Nurse, then by the head nurse… I almost thought that I saw the Chief Nurse’s signature thank goodness it wasn’t there.

Grabe. The doctor’s Diagnosis is AGE c Mild DHN (Acute Gastroenteritis with mild Dehydration). I meant that line to be “-no evidence of DRYNESS in the mucus membrane”, which supposedly would mean that the child is successfully being rehydrated. But for some reasons I have omitted the important word- dryness. I mean if I have forgotten mucus membrane the sentence will still mean what I mean, write? right?