Jason Hautala RN
Bo Stone: don’t worry about sounding too professional in your charting. As long as you chart what the coders can bill for, that is all that they really care about. I’ve decided to start having a little fun with my charting. Quoting patients in the ER is the most fun I have all day. Just to give the other health care professionals a better idea what type of patient they are dealing with, I quote them when they say, “I’m going to kill you and your dog you [deleted for the children] [deleted for the children] scumbucket.” Had the medical records lady ask me not to use expletives in my charting, but the docs backed me up and said it was reasonable to chart exactly what they say.
I also have charted the word “wenis” when referring to the loose, dry skin on your elbow, and I chart abscess location using quotes when they tell me they have a sore in their [deleted for the children].
Don’t get yourself fired doing stuff like this … I’m a professional, but really, chart what can be billed, chart what the lawyers want to see, other than that, chart what can either help your co-workers or amuse yourself 😉