Am I reading too much into this?

[Pepper The Cat]

Got a question for everyone - I'd really like some unbiased opinions.

First, back ground info: We do computerized charting, including shift report. Shift report is pretty much all done via the computerized charting and is therefore part of the chart. You can go way back and read shift reports from weeks back if you want.

So yesterday (Friday) part of my shift report was: Pt very tired today, states he did not sleep well due to roommate.

That was all I wrote about that.

I came in this am and read the report from nights.

It said (paraphrased) : Pt complained to Day Nurse that he did not sleep well last night. Pt was observed in bed with eyes shut. Pt was checked every hour and appeared to be sleeping. Pt was changed and did not complain of not sleeping.

There was more details than this, but you get my drift.

Basically, to me it came off as very defensive.

I never accussed the night shift of anything. I just stated that the pt stated he did not sleep well.

Just for the record, his roommate's report for the night the pt said he did not sleep well stated that the pt was using call bell frequently and yelling for the nurse.

What's everyone take on this? Am I reading too much into this, or is this nurse coming off as defensive towards me? :uhoh21:

I certainly did not accuse them of anything. All I said was the pt said he was tired!

[smstar1996]

Got a question for everyone - I'd really like some unbiased opinions.

First, back ground info: We do computerized charting, including shift report. Shift report is pretty much all done via the computerized charting and is therefore part of the chart. You can go way back and read shift reports from weeks back if you want.

So yesterday (Friday) part of my shift report was: Pt very tired today, states he did not sleep well due to roommate.

That was all I wrote about that.

I came in this am and read the report from nights.

It said (paraphrased) : Pt complained to Day Nurse that he did not sleep well last night. Pt was observed in bed with eyes shut. Pt was checked every hour and appeared to be sleeping. Pt was changed and did not complain of not sleeping.

There was more details than this, but you get my drift.

Basically, to me it came off as very defensive.

I never accussed the night shift of anything. I just stated that the pt stated he did not sleep well.

Just for the record, his roommate's report for the night the pt said he did not sleep well stated that the pt was using call bell frequently and yelling for the nurse.

What's everyone take on this? Am I reading too much into this, or is this nurse coming off as defensive towards me? :uhoh21:

I certainly did not accuse them of anything. All I said was the pt said he was tired!

Yes, I think your reading to much into this. The nurse was charting on the pt. Things put on 24 hr report need to be followed up on, and that is exactly waht she was doing. There were no problems noted on her shift, it was okay with waht she put, but I would of put, "pt resting in bed with eyes closed at long intervals. No s/s of distress noted. Call light in reach. Will continue to monitor." You also went another step to ask pt roomate about how the other pt sleep or did that pt volunteer that info. It doesn't matter, teamwork is important. You don't want to make enemies over small things like this b/c once all that is getting thrown around, write ups come into play.

[morte, LPN, LVN]

my take on this was that the noc nurse, went back and posted about the previous noc, not the present one, if that is the case, yes (s)he is being defensive, and inaccurate....and i think the op is right....

[medsurgrnco, BSN, RN]

The night nurse was documenting CYA style, as the pt made a complaint that appeared to that nurse to be inaccurate. The night nurse then wanted to protect herself/himself in case of any further complaints. This was not being defensive at all.

[ktwlpn, LPN]

The night nurse was documenting CYA style, as the pt made a complaint that appeared to that nurse to be inaccurate. The night nurse then wanted to protect herself/himself in case of any further complaints. This was not being defensive at all.

I agree-even a perfectly oriented patient can become a little batty in hospital.This patient could just be a chronic complainer which can result in thousands of dollars of un-necessary testing because the doc has to go with what they are told unless evidence exists to the contrary.I had a resident in the LTC claim that she was told to clean up her BM herself when she called for help using her call bell.I know this is not true because I answered the call.

[Roy Fokker, BSN, RN]

LOL! Yeah, I just love the ones who say "That damned nurse never gave me anything for pain all night long"... and here I have my documentation showing I rounded at least every 20 minutes (thanks to the pt. ringing the call bell every so often!) AND that I gave enough pain medication to sedate an elephant....

Sometimes it makes me wonder - do patients really think that by telling different stories to the nurse and the doctor they'll get away with it? Do they think that we nurses and docs don't talk to each other?

cheers,

[lpnflorida]

Haven't we all had the lone patient who swears up and down they did not sleep a wink, yet every 2 hour or 1 hour check indicated that they had their eyes closed and appeared to be resting? Back when I worked night shift, a patient who tried to tell me they couldnt sleep at night no matter what was done for them. I told them everytime you see or hear a nurse at your doorway at night. Verbally tell them you are still awake. hmmmmmmmmm never happened, so I guess in fact they were sleeping.

[leslie :-D]

me thinks it's cya charting, but who cares?

just continue to chart your assessments/observations.

reminds me of all the notes i've read about "pt appears comfortable, afeb, repo'd q2h, meticulous po care, lg soft bm..."

meanwhile, when i walk in, pt is moaning, t 103 w/thickened dried secretions coating mouth/tongue/teeth...

oh and of course, stage II's to boot.

gotta love cya charting.

leslie

[FireStarterRN, BSN, RN]

I think the night nurse is trying to document what he/she actually observed as opposed to the patient's claim of sleeplessness. Sometimes patients will report sleeplessness but never complain of it to the night nurse, will appear to be sleeping all night, then complain to the day nurse.

I wouldn't make any more than that of this.

[Pepper The Cat, BSN, RN]

my take on this was that the noc nurse, went back and posted about the previous noc, not the present one, if that is the case, yes (s)he is being defensive, and inaccurate....and i think the op is right....

That's exactly what she did. She wasn't reporting on her present shift, she was documenting on the previous one!

I've since learned that this nurse got in trouble because she didn't do something she was supposed to do one night (check O2 sats while pt was off O2) and it resulted in an extra night's stay for the pt because they didn't know if the pt was still de-satting through the night or not.

So I guess she was feeling defensive.

I'm not making anything more of the matter!

I