At the clinic where I work, I'm the only 3/4 time nurse. All others are full time.
Often, when I come back from a few days off, I'll be charting on a pt and notice that no one has been charting on them except for me.
We have pts who crash, get serious infections, get a lot of new orders, etc.
Recently, several pts have crashed. I looked in their charts several days later and saw that nothing had been charted about it.
Whenever I'm involved in or observe anything unusal, I chart it.
Recently, I've assisted others when their pts have crashed, vomited, had a blood loss, etc. And no one has charted on it. I've kinda been charting for other people in these situations. For example, I'll chart after the fact something like "I observed Nurse X administer 0.4mg nitroglycerin sl at 1314, 1319 cp was not relieved, V/S blah blah blah. Another dose of nitro 0.4mg sl was given by nurse X at 1319. I obtained a pulse ox reading of 90% at 1321, glucometer reading of 198 obtained at 1325...."
In other words, I've been charting as observing the actions of others, since they're not charting it themselves.
A couple weeks ago, I opened a pt's chart and saw that I'm the only person who has charted on her at all since Feb. I know this pt has had blood losses, chest pain, etc. on days I've been off and no one has charted it.
