In our facility we do chart checks; days do 12h checks, nights do 24h checks.
Recently I came across a patient sent to me who had a 12h chart check already done. Being the cynic that I am, I began reviewing orders so as to know what was the plan and ensure orders had been placed properly. What did I find? A chart where nary one order had been noted off, errors in a couple of orders, inaccuracies in medications this patient was supposed to be getting (i.e. Lasix and KCl had been completely forgotten, Norvasc never ordered...).
Needless to say, I promptly went to the beginning of the orders (patient admitted in the am, so not too many pages to traverse) and, one by one, began reviewing and noting off orders as I verified they were correct (this is the way ALL my chart checks are done...each and every order will be reviewed by me before I sign off a 12h chart check).
When I was done, I called the nurse who gave me the patient and told her what I had found and how she should never sign off a chart check unless she had been able to do the chart check, as this can be written up and is dangerous. She told me, "go ahead and write me up. I did the best I could." Seriously? This shoddy work is the best you could do? How did you pass nursing school
? Good God! How do you survive?
What I said was, "I do not have the time or desire to write it up. I am giving you a heads up that this is not right, not safe, and can get you in a lot of trouble, as it is considered falsification of documents, as a chart is a legal document. Please, next time if you cannot do the check, remember: we have 12h...if you are transferring the patient and do not have time to check the chart...DON'T. Tell the nurse getting the patient and let her do what needs to be done. We have until the end of the shift."
It still bothers me. When did we lose sight of accountability and responsibility? When did we stop caring whether or not we let errors slip right past us? When did we stop trying to do what was right just because it is the right thing to do, not because someone is watching us?