Nurse charting inaccurate vital signs...please help

  1. I have a problem and I need your opinion on this. In the hospital I work PRN as a Nurse Tech, the aides (or techs) are charting vital signs and I&Os. I have worked a few times with one nurse who refuses for me to chart the signs, she says she wants to do it on her own. That's fine with me, she has a right to do that. But at the end of my shift I check all the charts to make sure that everything is charted, and on her charts I notice the numbers do not match the ones that I provided to her. Some examples are, she changes respirations from 20 to 16, or the temp. from 96.2 to 96.9, O2 SAT from 91 to 95 or if a patient ate 40% of the meal, she charts 100%. I pick up the trays and I know they did not eat 100%.
    My problem here is, should I report that? I mean the changes are not life threatening, she just makes the vital signs look better. I know, if I report her, I could not work on that unit again. She would know who reported her. And she is not one of those nice people, you could confront and ask why, she would just go off on me for questioning her. She told everybody in the breakroom that she hates all f****** aides. The are so lazy, she has to do everything on her own. I did not say anything, but all nurses just looked at me at that point.
    I really need your help with this one before I call my supervisor.
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    About NurseLatteDNP

    Joined: Aug '05; Posts: 964; Likes: 208

    18 Comments

  3. by   UM Review RN
    I know that if I don't like what I see as far as vitals on any patient, I'll go in and sometimes recheck--and I'll get different answers.

    One tech in particular seemed to generate BPs that were up to 30 points higher than what I'd get, 15 minutes later! I know she was doing them correctly, I just think she had the type of personality that hyped patients up, instead of soothing them down, if you know what I mean.

    Other times, if I notice that someone may not have finished a meal, I'll try to give them something more as I make my rounds.

    What puzzles me is why she would not want you to chart your stuff, and then write a "recheck" set of vitals at the time that she repeated them?

    Furthermore, you do not need her "permission" to chart the vitals if it's in your job description to do so. Just do them and immediately chart them. If she has a problem with that, let her say so.

    If you have any questions, there's also no reason why you couldn't ask your NM for guidance.
  4. by   NurseLatteDNP
    You are right, I don't have a proof that she did not retake the vital signs, I never seen her do it, but that does not mean she didn't. I don't see a purpose in changing them like that. But the charting of the meals, I know she did not give them anything exta to eat. I made sure and asked those patients (all 5). So do you think I shall just not report it since I don't have the evidence? And I did not chart, because she keeps her charts at her desk, and tells me not to touch them, just to give her the copy of the vitals.
  5. by   squeakykitty
    Maybe you should keep watching, document what you see, before reporting it. Also, document your own work and cover your ass, just in case she lies about you to get you in trouble.
  6. by   NurseLatteDNP
    I am saving my vital sign sheets. I figure that would be a good thing to do, if she ever inaccurately charts critical vital signs. So I guess I wont tell. I am just afraid that this has been going on for a long time, and nobody knows about it.
  7. by   squeakykitty
    Quote from kiyatylese
    I am saving my vital sign sheets. I figure that would be a good thing to do, if she ever inaccurately charts critical vital signs. So I guess I wont tell. I am just afraid that this has been going on for a long time, and nobody knows about it.
    I would think that if she's not charting the meals accurately, she may not be charting the vitals accurately, either.
    Last edit by squeakykitty on Jun 2, '06
  8. by   nursedawn67
    Quote from squeakynurse
    I woukd think that if she's not charting the meals accurately, she may not be charting the vitals accurately, either.
    I was just thinking this too. Ok I could see the possibility of her rechecking the vs and charting her rechecks, but what about that food acceptance is she going in and feeding them more to "correct" that too (sarcasm). I think the vs to that nurse didn't seem "good enough" so she revamped them to meet her own approval...but this is my own opinion.

    I personally think this should be brought to someones attention because what else is she "fixing"?
  9. by   chadash
    Does it seem like when she rechecks, the vitals come out closer to normal? Could there be any motivation for her to be less than honest about this kind of thing. I am baffled.
  10. by   NurseLatteDNP
    Quote from chadash
    Does it seem like when she rechecks, the vitals come out closer to normal? Could there be any motivation for her to be less than honest about this kind of thing. I am baffled.
    Believe me, I am too. I have never seen this before. I mean why would you want to make vital signs look better? It does not serve any purpose
    (I think). All the vital signs she writes down are closer to normal. But I have never seen her use a dynamap. But she could say she rechecked it, if she is confronted.
  11. by   Daye
    i decided very early on that regardless of the circumstances i would never falsify anything i do regarding my pt care. i was mortified one day when the cna wrote vitals for the entire evening several hours ahead stating that the pt was unruly and difficult to cooperate with. since the pt was stable she opted to just forgo the formality of legitimate vital taking.....:smackingf
  12. by   daisey_may
    I know that it is in within your scope of care and job description, but why do you take the patient's vitals for this nurse when you don't chart them and the nurse doesn't use them? And you cannot make assessments and nursing diagnosis as an aide, and the nurse obviously isn't using them, so you're taking the vitals defeats their purpose. So does the nurse do this for EVERY SINGLE ONE OF HER PATIENTS ALL OF THE TIME or just when she pleases?
  13. by   NurseLatteDNP
    Quote from daisey_may
    I know that it is in within your scope of care and job description, but why do you take the patient's vitals for this nurse when you don't chart them and the nurse doesn't use them? And you cannot make assessments and nursing diagnosis as an aide, and the nurse obviously isn't using them, so you're taking the vitals defeats their purpose. So does the nurse do this for EVERY SINGLE ONE OF HER PATIENTS ALL OF THE TIME or just when she pleases?
    She does not know that I rechecked the charts. And I think she uses my vital signs as a baseline. She wants me to take the vitals and then give a copy of it. I don't know if she does it every time, because I rarely work with her ( ). But she does do it while I am there.
  14. by   RunnerRN
    Quote from daye
    i decided very early on that regardless of the circumstances i would never falsify anything i do regarding my pt care. i was mortified one day when the cna wrote vitals for the entire evening several hours ahead stating that the pt was unruly and difficult to cooperate with. since the pt was stable she opted to just forgo the formality of legitimate vital taking.....:smackingf
    oh holy poop. you have to hope that is one cna that doesn't want to go on to nursing school. i don't know what is worse...the fact that she falsified the vitals, or that she told you straight out. i worked with a nurse once who flat out told me she had written down false d/c vitals on a patient of mine i had asked her to sign out. you'd better believe i ran after that pt to get real vs and have never let her touch another pt of mine since.

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