My family tells me that when I was a very little girl, I apparently had a proclivity for creating my own language that only my older sister could interpret. It took some coaching but eventually I adapted to the standard American language for everyday words.
Well, except one — I guess my family thought was hysterical to not tell me the correct pronunciation for spaghetti until wayyyy into grade school. Which I called pissghetti. (Not amusing Mom and Dad!)
Now, some people actually think an invented word they hear often are real words. Like “irregardless.” This isn’t a real word people! It’s a double-negative, making it meaningless. But, if you said it, (sigh) I would kind of know what you meant.
However, I still do invent words. But to be honest, I believe they have understandable meaning and am hoping for neologism (a word that may be in the process of entering common use). For example, every day I “procaffeinate”. Meaning I put off talking to anyone or making any decisions of importance until I have had at least two cups of coffee. See, definition clear.
Or how about what all siblings do when you are young which is “blamestorming.” Yep, you know what I mean. “I didn’t break that vase, Johnny did it.” Or how about “athlethargy” which after a long day I am often guilty of. Where sitting in front of Netflix wins out over the gym.
And while all of this is fun and games verbally, no one gets hurt. You just don’t, ever, ever, ever (yeah, one more time for emphasis) put this in your patient’s documentation. Like, never! I have to wonder why some people put in writing the things they do. Do they think we are inside their heads and can just string together these random thoughts or made-up acronyms? Do they think that someone outside of the facility knows the intimate details of the situation that they left out of the documentation? I really am not sure. But all I can say is, what I see in documentation in medical records is enough to scare my curly hair straight!
I saw a documentation once that said, and I quote, “Resident FTD. Called family.” That was it. No more hints or clues; end of documentation. Now, I am wondering, “Hmmm, I know the facility has a van. Does this resident think they are a florist and was trying to steal the van?” So, I called the facility and asked to speak with this nurse. She gets on and when I ask what this indiscriminate acronym means, she calmly explained that FTD means “fixing to die” and in such a way that I must be the biggest idiot not to know that. (Five minutes later, she understood why we do not do that!)
But I also see on almost a daily basis nurses documenting in so few details that I have no idea why, for example, the resident was sent to the hospital. And when I reach out to the DON requesting a clarification, I will later get several paragraphs. My response always most emphatically (but politely) is, “And how could we all know that from the documentation?” Literally, people, 30 more seconds of documentation would save us all from so much trouble (including future trouble).
We don’t need a book, we don’t need a soap opera, and we don’t need to channel Nicholas Cage’s character Benjamin Franklin Gates from the “National Treasure” movies to figure out what someone has written.
Please, I am begging you, just write what happened in a way that someone who is NOT YOU will understand, what you did about it and what the outcome was. Otherwise, I swear I’ll be FTD shortly!
Just keeping it real,
Nurse Jackie
The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, Senior Director of Clinical Innovation and Education for Mission Health Communities, LLC and an APEX Award of Excellence winner for Blog Writing. Vance is a real-life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.
Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.
