"Unusual charting" - page 3

I found some very "unusual charting" when I was looking over the nursing notes on one of my private duty patients. One of the nurses was doing what sounded like " her own opinion charting." She charted that the nurse on the... Read More

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    I'm surprised I haven't seen this mentioned yet... Always keep your own personal "notebook" of some sort. Keep notes on this kind of thing, making sure to document date, time, and people involved. This type of thing tends to blow up at the worst times. Those kinds of nurses will take everyone down with them that they can. I like to use e-mail instead of calling and talking with a supervisor. That way I have written proof that I contacted the supervisor with an issue. Then they can't say they were never told or any other excuse. If anything ever goes to court you will also have your own documentation with dates and times that events occured. And the attorneys will have a field day with that nurses documentation. Just make sure your documentation is accurate and complete. This nurse will bring attention to herself and it will bring attention to your documentation as well.

    When I end my notes for the shift I always document to cover my !@#! As it applies to the patient I will document things that someone could come back to me on or document against me for the next shift. I write things such as "diaper dry", pulse ox on (insert body part). I write that the equipment is working properly and plugged or charging as it applies. I have come in to shifts where the nurse unplugged something like the suction machine and it was dead when I needed it. So I always make sure things are plugged in and charging and I document it so nobody can come back and say it wasn't done. After writing diaper changed I document that pericare was given. All of that is done to protect myself.
    If I come in to a shift and something wasn't done by the last shift I document it so that the reader must read between the lines. I never do it like I'm pointing fingers. If you read my first note of the shift as "Void. Diaper changed. Pericare given." Or Diaper saturated. Diaper changed. Pericare given" You will know that the last nurse probably left the pt in a wet diaper. I had a parent turn a continuous feed off because she thought the kid was "getting fat" from the feed. She would turn the feed off for many hours at a time. The child was severely under weight and social services was involved. The mom would turn off the feed and tell me the childs stomach was hard as she was feeling the pelvic region. I would document that the pt's mom turned the feeding off and states the patients stomach is hard. Then I would document Abd. reassessed. Abd. soft, NT, ND. Pts mother re-educated on nutrition needs.
    Always document to cover yourself during your shift and for what could be accused or documented after your shift. Then you won't have to worry about what the other nurse writes :-)
    Kyasi and Blackcat99 like this.

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  2. 0
    Quote from SDALPN
    I'm surprised I haven't seen this mentioned yet... Always keep your own personal "notebook" of some sort. Keep notes on this kind of thing, making sure to document date, time, and people involved. This type of thing tends to blow up at the worst times. Those kinds of nurses will take everyone down with them that they can. I like to use e-mail instead of calling and talking with a supervisor. That way I have written proof that I contacted the supervisor with an issue. Then they can't say they were never told or any other excuse. If anything ever goes to court you will also have your own documentation with dates and times that events occured. And the attorneys will have a field day with that nurses documentation. Just make sure your documentation is accurate and complete. This nurse will bring attention to herself and it will bring attention to your documentation as well.

    When I end my notes for the shift I always document to cover my !@#! As it applies to the patient I will document things that someone could come back to me on or document against me for the next shift. I write things such as "diaper dry", pulse ox on (insert body part). I write that the equipment is working properly and plugged or charging as it applies. I have come in to shifts where the nurse unplugged something like the suction machine and it was dead when I needed it. So I always make sure things are plugged in and charging and I document it so nobody can come back and say it wasn't done. After writing diaper changed I document that pericare was given. All of that is done to protect myself.
    If I come in to a shift and something wasn't done by the last shift I document it so that the reader must read between the lines. I never do it like I'm pointing fingers. If you read my first note of the shift as "Void. Diaper changed. Pericare given." Or Diaper saturated. Diaper changed. Pericare given" You will know that the last nurse probably left the pt in a wet diaper. I had a parent turn a continuous feed off because she thought the kid was "getting fat" from the feed. She would turn the feed off for many hours at a time. The child was severely under weight and social services was involved. The mom would turn off the feed and tell me the childs stomach was hard as she was feeling the pelvic region. I would document that the pt's mom turned the feeding off and states the patients stomach is hard. Then I would document Abd. reassessed. Abd. soft, NT, ND. Pts mother re-educated on nutrition needs.
    Always document to cover yourself during your shift and for what could be accused or documented after your shift. Then you won't have to worry about what the other nurse writes :-)
    Thanks for the great advice. Yes, I am going to bring a notebook and write down word for word what super nurse said in her recent charting. I am also going to be more careful with my own charting.
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    Doesn't the mom/dad read the notes? If I saw this, I would have something to say about it. Comments like this belong in the communication book. Although, TBH, I have seen some comments in there that really ****** me off. For a while we had Nurse-holier-than-thou covering for a nurse recovering from surgery. She was a decent nurse skill wise but she was super condescending to the other nurses, especially my two new grads that I had taken under my wing. They were both smart women with no experience and they became great nurses. And she would say one thing to me and just the opposite to my husband and seemed to be inserting herself where she did not belong. She is gone now. She didn't last three weeks with me and the agency canned her shortly afterwards for a med error.

    SDALPN, your charting sounds impeccable.

    To Blackcat99 and the other nurses working for agencies that tolerate (condone?) this behavior - I am sorry that you have to work under these conditions. I know it's hard enough working for some families even when you work for a good agency but to have lousy families AND lousy agencies is just the pits.
    Blackcat99 likes this.


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