Abbreviation question

[akflightmedic]

Funny that WNL as I posted was taught to me by a very experienced CCRN with years of experience in EMS, nursing, HEMS/HAA, ICU/CCU. But I guess you all know better than she or the attorneys.

The Brady makes my point. You would document it as “WNL”, when it’s not, as I don’t have bradycardia.

I am telling you how the electronic charting is within nursing. You click WNL with each body system. But I guess on experienced CCRN trumps the current medical practice in a dominant part of medical charting systems.

As for the Brady, I clearly said I would not document WNL as you incorrectly stated above. Go back and read. I said I would document the rate, document asymptomatic, and then quote the patient who said “that’s my normal”.

Slow down your keyboard.

 

[DrParasite]

Dude, just grow up. You’re out of your depth.

great response... don't actually address the actual facts, or your incorrect statements, just throw a personal attack or two, and hope no one picks up on it. doesn't change the fact that you are still ignorant to what you are talking about, but that's ok, because you aren't fooling anyone, except for maybe yourself.

I don't think I've ever written "-HAM" and/or "Vitals WNL" but if so, that'd have been in the narrative paragraph section. Meanwhile all the PCRs (paper and electronic) I've dealt with had dedicated spaces to write in the actual History/Allergies/Medications/Vitals, so even if written in the Narrative that way, the more detailed specifics are still documented on the form.

That's how the vast majority of PCRs are designed. Only an idiot would write WNL, and not actually specify what the vitals were in the appropriate vital signs section of the PCR.

 

[Carlos Danger]

So my episode of bradycardia was WNL. Ok. You do you.

Maybe a heart rate less than 60 is WNL, and maybe it isn't it. It all depends on the patient and the circumstances. A 24 year old athlete resting quietly with no complaints whatsoever? WNL. A patient just coming out of the OR who recently received opioids and a bump of phenylephrine and is in a NSR? WNL. An overweight 60 year old in 3rd degree heart block? NOT normal, so you would not chart it as such.

The point is this: documentation by exception IS a legally defensible charting strategy which is WIDELY used in both medicine and nursing. In fact, it is the default that practically everyone outside of EMS is taught.

I strongly doubt that anyone has EVER gotten in legal trouble for using "WNL" or "unremarkable" in their charting, ever. The caveat being a scenario where "WNL" was documented but was not an accurate assessment, in which case we are talking about another thing entirely.

 

[FiremanMike]

As the QI guy for my department which takes approx 6500 EMS runs per year, I have read every single PCR written here for the last 6 years.

I can say without a doubt that it is generally pretty obvious to identify the people who write WNL because they didn't check based on their treatment choices and overall documentation.

 

[DrParasite]

I can say without a doubt that it is generally pretty obvious to identify the people who write WNL because they didn't check based on their treatment choices and overall documentation.

As the QI guy who reads every chart: do those who don't check also not document numerical values elsewhere on their PCR? And if that is the case, does that not raise QA flags? or are they falsifying their documentation?

 

[FiremanMike]

As the QI guy who reads every chart: do those who don't check also not document numerical values elsewhere on their PCR? And if that is the case, does that not raise QA flags? or are they falsifying their documentation?

That's a long and drawn out answer.

The short version is, there are people I suspect are making up vitals, but I won't ever be able to prove it.

 

[DesertMedic66]

That's a long and drawn out answer.

The short version is, there are people I suspect are making up vitals, but I won't ever be able to prove it.

If you are using any sort of cardiac monitor, you can very easily prove it.

 

[FiremanMike]

If you are using any sort of cardiac monitor, you can very easily prove it.

This entire thing is a huge can of worms, lol

Some day, if conferences come back and we have an "emtlife" forum get-together, I'll unload the whole thing lol