16. Weak vs. strong documentation
Paired entries for this system. The left column is denial-bait; the right column is the same clinical picture written so a reviewer can see why a nurse was required.
Weak — does not survive | Why it fails | Strong — defensible |
|---|---|---|
“Line intact.” | No site, patency, securement, or sterile-care assessment — a layperson observation. | “PICC site clean/dry/intact, flushes without resistance with brisk blood return, securement intact, length unchanged; sterile dressing changed.” |
“Dressing changed.” | Records a task, not technique or site assessment. | “Sterile no-touch dressing change with chlorhexidine per order; site without erythema or drainage; dressing labeled and dated.” |
“Site looks red.” | No measurement, no systemic signs, no action. | “New 1.5 cm site erythema with purulence and temp 101.6°F; concerning for CLABSI; cultures per order, MD notified, line removal pending.” |
“Tube flushed.” | No patency judgment, no residual, no tolerance. | “G-tube patent, flushed without resistance, residual 30 mL, feeding tolerated; site intact without leakage; securement disc at 4 cm unchanged.” |
“Educated on line care.” | No content, no learner response. | “Site care, flushing, and dislodgement response taught; caregiver return-demonstrated clamping and pressure correctly; infection signs reviewed.” |
“Drain in place.” | No output, no character, no trajectory. | “JP drain patent and recompressed; output 15 mL serosanguineous, down from 30 mL; site intact; trending toward removal criteria.” |