so my question is, am i wasting my time physically assessing my patients?
we can only be responsible for our own actions. what would your nursing instructors have told you? do what you know is the right thing to do.am i doing something wrong?
no. in fact, you are doing everything correctly.
suggestion. . .(1) check the policy and procedure manual. see what the documentation guidelines are for your facility. they have them because it is actually a jcaho requirement that each patient be assessed and it can be found in the jcaho accreditation manual for hospitals in the section for provision of care, treatment, and services:
- initial assessments are performed as defined by the hospital.
elements of performance for pc.2.130:
- each patient is assessed per hospital policy.
- each patient's initial assessment is conducted within the time frame specified by the needs of the patient, hospital policy, and law and regulation.
- a registered nurse assesses the patient's need for nursing care in all settings, as required by law, regulation, or hospital policy.
0 - patients are reassessed as needed.
the scope and intensity of any further assessments are based on the patient's diagnosis; the setting; the patient's desire for care, treatment, and services; and the patient's response to any previous care, treatment, and services.
each patient may be reassessed for many reasons including the following:
element of performance for pc.2.150
- to evaluate his or her response to care, treatment, and services
- to respond to a significant change in status and/or diagnosis or condition
- to satisfy legal or regulatory requirements
- to meet time intervals specified by the hospital
- to meet time intervals determined by the course of the care, treatment, and services for the patient
- each patient is reassessed as needed.
although the jcaho manual element of performance is continually saying: "each patient is reassessed as needed
" that doesn't mean that the hospital nursing staff has carte blanche to determine when to assess patients. jcaho will expect that the nursing department will have policies and procedures directing nurses when assessments are to be done. (2) in some hospitals staff nurses are permitted to become members of a nursing council where these kinds of issues are addressed and managed and you can still maintain a staff nurse status. otherwise, consider working toward becoming a supervisor or manager so you can get involved in policy, procedure and enforcement and can do something about the people who are not doing things the way the facility policy and procedures say they should.
if you know others are falsifying their nursing documentation by recording assessments that they are not doing, that is a violation of the nursing law of just about every state. if you know that is happening, you need to report it to your manager. if the manager ignores you report it to the person who is the manager's boss and keep going up the chain of command until someone listens to you. in most places i worked falsification of the records was serious grounds for termination and when i was a manager we (the director of nursing and director of human resources) fired a nurse tech who was making up vital signs and blood sugars and posting them in the individual patient charts. we had another rn in a nursing home where i was a supervisor that was doing it with blood sugars and medications that she was charting and not doing, but she quickly packed up and quit when she realized she was being watched and evidence against her was being collected.
i am never pleased about managers that would hire new grads to work on a telemetry unit. that alone, i think, is indicative of poor judgment made by the person(s) who hired you. it tells me they don't care about the nurses. managers that will do this are usually only interested in filling holes in their work schedules. only experienced nurses should be hired to work on telemetry units. i worked on one for many years. i am not criticizing you. i think it's commendable that you are surviving there. i'm willing to bet that assessment problems are only the tip of the iceberg and that there are probably all kinds of policy and procedure violations going on.