Quote from dekatn
I I don't mean to come across as crude or rude, but you really do have to be careful about what you actually know for a fact and what you might assume. I'm not trying to imply that there aren't nurses that probably do some of these things, but, as the above poster stated, you have to learn how to choose your battles when you go to war.
You're right that one has to be careful and not assume that just because something looks one way to you that's the way it is. And certainly, there many little things that just aren't worth the effort to pursue. If someone is new to a facility, they usually should wait awhile before tackling anything beyond their own responsibilities as they might realize their first impression was incorrect. However, if something that looks amiss, it's not a good idea to always just assume everything's okay since no one else seems to be bothered by it.
If, over time, certain problems seem to continue, then it's right to address them. In most cases, addressing the person in question is the best place to start. Simply ask them what happened or if you (the person asking) missed something. Now is a good time to assume the best - that it's either on honest mistake on their part or a misunderstanding on your part.
If this doesn't work, then get some documentation together (evidence of the questionable documentation/actions) and bring your concern up to management. Again, approach it as an issue you're concerned about and not as if you're "turning someone in" or "tattling." Perhaps in collecting the info, you might realize that these are just honest mistakes that aren't worth making a big deal over. Or you might find a bad trend that should be addressed.