Ever had an MD document things to make you look bad?

Specialties Ob/Gyn

Published

Specializes in Psych, ER, OB, M/S, teaching, FNP.

Was just working with an MD delivering a G2 P1 39 5/7 wks pt. Baby was born pale, limp, no cry and HR of 100. The MD put the babe on mom's chest, within about 45 seconds I noticed that fan that had been on mom in the room was still on and told the MGM to turn it off. Was trying to dry and stimulate babe on mom, my respiratory therapist was handing me dry blankets to use on babe. After about 3 minutes I said I needed to get baby to warner. The whole time the family and mom is saying, "Why isn't he crying, why doesn't he cry?" At the warmer babe still not crying at 5 min. still pale, HR 110, getting O2, temp 95.2. MD says, "Do you have the pit running", because mom started to bleed pretty heavily, so I had to leave babe with RT and go hook up the pit (it was on the IV pole just not hooked up). MD comes over and at that point I go to Mom (we only have one nurse in room with delivery).

I wrote APGARs as 6 (1), 7 (5), 9 (10). I knew the doc would be mad, she never wants any of her pts to have any problems. Babe was 5 lbs, 5 oz and looked like crud. His mom was quite the smoker........

Anyway, doc wrote in her note that I read the next day that baby had good cry and good tone at birth but nursing did not remove wet blankets, left the fan on in the room and did not have the warmer on properly! She also crossed out some of my numbers (minutes for pushing) and wrote in her numbers. And she wrote that the CRNA bolused the epidural 15 minutes prior to delivery and I had documented that he came 36 minutes prior to delivery (not sure what he has written).

I am so mad I want to quit. I took it to my DON and we will see what happens. Her charting makes everyone look bad, and I am worried about the baby. He is a high risk for SIDS with mom being a heavy smoker, SGA and male and time of year.

I don't think I can work with her any more, I can't trust her.

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Specializes in Pediatrics, Nursing Education.

No - but I had an RT do it once. I brought the documentation to my manager, and my manager gave it in tern to her manager, and she was FIRED (she was PRN and a new hire).

We had a disagreement over a patient - she fussed when I called her and told her I needed a PRN TX. I ended up getting her coodinator to come and do the treatment. I could have just throttled this RT!!

The patient was a 6 month old with resp. illness, and I was having trouble keeping her sats high enough. She needed an SVN treatment. The RT on the phone was like... "well I was just there 30 minutes ago. Do I really need to come back?" YES, the patient changed!! and kids can change quick!

She trotted in (quite a while later) and she was like - why do you have her on oxygen now?

I told her because her sats are low, she was having dyspnea, and I am having very little results with suctioning and repositioning... so now we've gone to oxygen. And she needs that treatment I asked for!!!

The RT girl was like... she doesn't look that bad, I don't think she needs a treatment - and my shift coordinator prompty picked up the phone and called the RT coordinator in and he came up and he was like - this baby sounds like crap, she's wheezing all over and needs a treatment!!! (which was exactly what I told RT girl).

My nurse working with me was like - OMG, she is the worst RT ever!!! We had some other issues that night with her too... she knew we both weren't happy with her and she documented on my chart a BOOK when you're supposed to do 2-3 lines. And the way things were worded was none too nice.

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Specializes in Pediatrics, Nursing Education.
Was just working with an MD delivering a G2 P1 39 5/7 wks pt. Baby was born pale, limp, no cry and HR of 100. The MD put the babe on mom's chest, within about 45 seconds I noticed that fan that had been on mom in the room was still on and told the MGM to turn it off. Was trying to dry and stimulate babe on mom, my respiratory therapist was handing me dry blankets to use on babe. After about 3 minutes I said I needed to get baby to warner. The whole time the family and mom is saying, "Why isn't he crying, why doesn't he cry?" At the warmer babe still not crying at 5 min. still pale, HR 110, getting O2, temp 95.2. MD says, "Do you have the pit running", because mom started to bleed pretty heavily, so I had to leave babe with RT and go hook up the pit (it was on the IV pole just not hooked up). MD comes over and at that point I go to Mom (we only have one nurse in room with delivery).

I wrote APGARs as 6 (1), 7 (5), 9 (10). I knew the doc would be mad, she never wants any of her pts to have any problems. Babe was 5 lbs, 5 oz and looked like crud. His mom was quite the smoker........

Anyway, doc wrote in her note that I read the next day that baby had good cry and good tone at birth but nursing did not remove wet blankets, left the fan on in the room and did not have the warmer on properly! She also crossed out some of my numbers (minutes for pushing) and wrote in her numbers. And she wrote that the CRNA bolused the epidural 15 minutes prior to delivery and I had documented that he came 36 minutes prior to delivery (not sure what he has written).

I am so mad I want to quit. I took it to my DON and we will see what happens. Her charting makes everyone look bad, and I am worried about the baby. He is a high risk for SIDS with mom being a heavy smoker, SGA and male and time of year.

I don't think I can work with her any more, I can't trust her.

That is rediculous. And it places all of you at a higher liability than if she had just left it alone. i don't think she was trying to make you look bad out of spite, but i think that she wanted to get the liability OFF of her - and you're the scapegoat!! what a way to make friends, huh?

Some people do really stupid things, even if they are docs. i'm sorry about the baby, i hope that they do really good teaching before he leaves the hospital.

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To me what the physician did was illegal.

You have your charting, the physician has theirs.

To me, the physician doesn't have the authority to change NURSING charting.

This is what is beautiful about computerized charting...no physician access.

I would do an incident report to cover your butt.

When I worked L&D as an Extern this summer, the fist thing that they warned me about was an OCD OB that we had that used to be an attorney...they said he would compromise the patient and falsify charting in order to cover his butt (that's the attorney in him), and they said it was only a matter of time before he killed someone.

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Specializes in LTC, MDS, Education.

I have a feeling that if the NURSE changed the DOCTOR'S notes, the nurse would have been fired AND reported to the Board of Nursing! Where is the justice? :uhoh3::confused:

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Specializes in Med/Surge, Psych, LTC, Home Health.

That's a big load of doo-doo. What the doctor did was illegal, plain and simple. They need to be reprimanded. You do whatever you can to cover your butt. I agree with making an incident report.

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That's a big load of doo-doo. What the doctor did was illegal, plain and simple. They need to be reprimanded. You do whatever you can to cover your butt. I agree with making an incident report.

Report the doctor to the state board of medicine. And send a copy to the administration and the senior partner of the law firm who represents the hospital. And keep copies for yourself. JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Spokane, Washington

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Yes, in a way. It was he said she said. The MD believed the pt and filed a report against me. Stating I let her off the unit for 4 hours, to use drugs, when she was literally gone for 2 minutes. I sat her at the nursing station waiting for security to come escort her. Call bell by the RN station rang. Told her to sit tight. Answered the bell. Turn around and she is gone. Literally 2 minutes she returns accompanied by a staff member. Needless to say I document everything from now on.

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Specializes in OB/GYN & Med/Surg.

that's a big load of doo-doo. what the doctor did was illegal, plain and simple. they need to be reprimanded. you do whatever you can to cover your butt. i agree with making an incident report.

t-totally in agreement!!! :up: that was unethical, illegal & bad all around. :nono: definitely, file the report & keep a copy. :typing cover your butt. you worked too hard for your license for some nasty-attitude doctor to try to take it away! :madface: grrrrr (thankfully, i haven't ever had this happen to me from a coworker - just patient's family grrrr!) :argue:

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Specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.

This post just makes me see red!! I agree with Lindarn--this doc needs to be reported to the state BOM. It is illegal to falsify records--especially someone elses!

Shame on this doctor!

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I have not personally encountered this, but one of my preceptors when I was in school had a doctor who falsified some records to CYA regarding a lawsuit - which, BTW, was legitimate - and she had the original records. Not only did the patient win the lawsuit, the doctor faced very significant disciplinary action. I don't remember exactly what it was, but this doctor was unable to practice for some time.

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Specializes in Ante-Intra-Postpartum, Post Gyne.

Isn't it illegal for the doc to cross out your stuff and write above it?!?!? I would be making a report!!!!

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