Charting error during clinicals

  1. 0
    While doing my clinicals I charted a baby's resp at 29. The norm is 30-60 according to policy. When my clinical instructor saw that she flipped. She called me over to the file and
    demanded `what is the norm?' I said 30-60 she said `what?' angrily so I said 40-60....
    she said then demanded i go immediately and redo the resp.
    Which I did and the were higher at 42. In the chart the baby had resp 32 earlier, the baby was pink, no distress, no nasal flaring, no grunting, the baby was sleeping on his mom.

    My instructor has written me up and I am on probation because of this. Other times when I asked about similar situations ( heart rate not in norms...she said its ok)
    it did not even occur to me that the baby was in danger.(and the baby was NOT) I was in and out of the room multiple times in the 2 hours from the time i took the first resp rate till she read the chart.
    When she wrote me up I did not defend myself or make excuse but I feel my file should also have my version of the events....any comments?
    How will this affect my future career?
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  3. 6 Comments so far...

  4. 3
    First this should NOT effect your future!I hate to hear this, teachers writing up students, yelling at them and making them feel dumb instead of teaching.When I have to chart somthing that is abnormal I always annotate along with it. For example: resp 29, pt is pink, other vs wdl, no signs of respiratory or other destress, appears to be sleeping. Will monitor. Just make sure you reassess.
  5. 0
    [FONT=verdana]
    "In the chart the baby had resp 32 earlier, the baby was pink, no distress, no nasal flaring, no grunting, the baby was sleeping on his mom."
    I should have indicated in previous post that I was the one who told my instructor the baby's condition it was not written in the chart only the resp of 32 was charted.

    I am receiving a conditional pass and a letter is going into my school file. My side of the event was not recorded. and no one asked me...should I go to the director and ask that my side of the events be recorded as well.
    I was also told that any future clinical instructor will have to supervise me....(like I am completely incompetent!?) There was never any danger...except now to my self confidence and my future career.
  6. 0
    You need to watch your step around this instructor. Some of them can be unreasonable and mean to students, which does nothing to create a positive learning experience. I was fortunate to have great instructors, but I remember hearing some horror stories when I was a student. Ultimately, you need to pass clinical, so make sure she sees that you are taking initiative throughout the rest of the term. Do your readings, know the policies for your unit, show up prepared. In the big scheme of things, this won't hurt your career. In fact, I know of people who were held back who are now good nurses in practise.
  7. 0
    You are also within your rights to request that a typed up statement of your version of the events be added to this file. I would recommend doing so, for your peace of mind. Otherwise, treat this as a learning experience and move on.
  8. 1
    I want to add that you should get into the habit now of rechecking abnormal vitals immediately, or at least within a few minutes. That is the first thing I tell nursing students (and some nurses) to do when they bring me abnormal vitals.

    If you used a machine the first time around, recheck VS manually because machines can be notoriously inaccurate at times. If you checked VS manually for only 10/15/30 seconds, recheck them again manually but for the full minute.
    grpman likes this.
  9. 0
    Thank you all for your comments.


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