Quote from mikala3
i helped out a nurse that was overwhelmed and a verbal warning for not following up on a pain medication. i have not just nursing notes and shift assessments to do, but i also have three other online "forms" to fill out on patients. one of them is tricky and the program likes to delete your entry. i forgot to check that it didnt delete and was actually there..... and of course it deleted instead of saving. i got written up for not completing the proper paperwork on my patients.
this is a system failure, not a nursing failure. you have enough to do without having to take the time to double check that your documentation was saved. you are spending way too much time and having unnecessary anxiety over something that shouldn't be your problem. you charted, as you should have and the program deleted your entry. that's a lawsuit waiting to happen, and needs to be addressed by your nm immediately. i can't believe that this has been an on-going problem on your unit that hasn't been addressed. if your nm says that it can't seem to fix the problem in a timely manner, then paper charting should be used until the glitch is fixed. this is not your fault. don't own it, but do be proactive in voicing your concerns to your nm about this. you should not have been written up for this, and i am shocked that your nm spent time composing the paperwork to write you up instead of getting on the phone to it to fix the bug. this is a risk management issue.
i got a verbal warning because i got cold and put a jacket on and it covered my name badge.
seriously? at least you came in to work your shift instead of calling out sick. this seems petty to me.
i have a horrible night shift. a nurse went home sick, and one had called out leaving us short two nurses. i had three discharges, two admits and five patients that i only had "for a while" during one eight hour shift, i also gave meds to four patients that belonged to two other nurses because everyone was overwhelmed. i could care for the patients, that is not the problem, my problem is that i am now dreading answering questions about why i did or didnt do something on that day (paperwork related of course). i gave insulin that was well over an hour overdue to three patients that werent mine. i just feel a write up coming for late meds.
is this nursing? fearing my job over petty issues? being afraid to help someone out because i could get written up for their lateness? do i have the wrong job? (this is my first nursing job).
it is refreshing to hear that you are such a team player. it seems to me that there is a horrendous flaw in the documentation system your unit is using, and that makes it difficult to be excited about your job. you are subconsciously having undue anxiety regarding the actual saving of documentation...that is not your fault. if the facility can't give you the tools to do your job in a precise and accurate manner, then the system needs some scrutiny. talk to your nm about it, and if s/he isn't receptive to getting the problem fixed, put your notes on paper to protect yourself.
furthermore, email your nm regarding the problems in the system, providing factual and detailed information. for example:
i noticed that there seems to be a computer glitch in our charting system. this morning at 0747, i documented my notes on pt x in room 101-a. i opened the chart again at 1143 to chart additional information and noticed that my notes from 0747 were not saved. i am concerned about our charting system because it is not saving pertinent information that i am charting. as you know, documentation is the only way to prove our implementations, and our charting system seems to be failing in this regard.
can we meet sometime this week to talk about this? i know that your goal is patient safety, and timely documentation is key to our goal in providing safe patient care.
thanks for your time. please let me know when we can meet to discuss this.
if you email your nm, you have solid documentation that you are concerned with this system glitch while voicing that you don't have the tools you need to do so. you left the ball in his/her court as to how the problem should be addressed. if your nm does not follow up on this, you now have proof that you did, in fact, address this problem with the nm, and it is out of your hands.
meanwhile, chart on paper to ensure that your documentation is present. this is your license.