Vent to/about my "coworker".

CloudySue · Mar 16, 2014

Sorry somebody's touching your documentation, that's such a big no-no. I worked once in a place where the amount supplies was abounding. "Restock supplies" for some reason was on the MAR instead of the cleaning checklist, why who knows. It was I think my first time there did what I thought was a pretty good job of digging through the closets and brought everything up to a decent level. When I came back, some other nurse CIRCLED my initials for that. I wrote a note telling whoever did that to never touch my initials again and if they have a problem with any job I do, to take it up w the clinical manager to reeducate and retrain me.

caliotter3 · Mar 16, 2014

Sad situation is when the supervisor does absolutely nothing about the tampering with documentation or worse yet, makes excuses for, or otherwise supports the actions of, the employee that does this.

HisTreasure, BSN, RN · Mar 16, 2014

Very often it's the parents, too. I've seen a caregiver come in, check the nurse's communication book (that's intended for the nurses, only) check the MAR/TAR and mark up the book with question marks crossed out initials or whatever. When approached about it she would say it wasn't done or done to her liking so the nurse shouldn't have checked off it was done. It's false documentation and she was making note of everything to report to the Supervisor at the monthly visit. It took the Supervisor telling her that her addendum falsified and compromised the integrity of the record (which could lead to decreased hours at recert) that made her stop. Even though we had said the same thing over and over. Then it became Post It notes everywhere.

smartnurse1982 · Mar 16, 2014

I actually tell parents to check the Mar.

It is intended for them to view only though,not place marks on.

For ex... a nurse leaves at 7am.

The client has meds due at 7am.

i usually give the 7am meds,but some nurses do not do it,even though you can give them 1 hr before and after.

If mom assumes the nurse gave the med,then the kiddo would miss the meds due at 7am.

smartnurse1982 · Mar 16, 2014

Would you believe some Dr's dont give parameters?

i had to go through a lot of hoops to get this 1 doc to write parameters for albuterol.

He just gives orders that say" give albuterol q 4 hrs prn".

JustBeachyNurse, LPN · Mar 16, 2014

I actually tell parents to check the Mar.
It is intended for them to view only though,not place marks on.
For ex... a nurse leaves at 7am.
The client has meds due at 7am.
i usually give the 7am meds,but some nurses do not do it,even though you can give them 1 hr before and after.
If mom assumes the nurse gave the med,then the kiddo would miss the meds due at 7am.

The nurse when reporting off to the parent needs to be clear whether due meds were given or not. It is not parental responsibility to check the mar. If this is an issue the clinical supervisor should consider moving medication time to 6:30A so it is clearly nurse responsibility to give med. this is a training. & policy issue.

If a coworker is altering your documentation that can be fraudulent. If you cannot speak with them directly then consult with clinical supervisor. You are most likely NOT the first person the coworker did this to and corrective action is needed ASAP. Especially since it appears you did not perform a task by him/her circling your initials

SDALPN · Mar 17, 2014

The nurse when reporting off to the parent needs to be clear whether due meds were given or not. It is not parental responsibility to check the mar. If this is an issue the clinical supervisor should consider moving medication time to 6:30A so it is clearly nurse responsibility to give med. this is a training. & policy issue.
If a coworker is altering your documentation that can be fraudulent. If you cannot speak with them directly then consult with clinical supervisor. You are most likely NOT the first person the coworker did this to and corrective action is needed ASAP. Especially since it appears you did not perform a task by him/her circling your initials

Exactly. It's never a good idea for a parent to be looking at our paperwork. Also, many parents aren't capable of learning how to read the mar. Many have told me they don't understand it and I have a few parents are illiterate. I had one family mad because the 485 wasn't accurate, even when it was explained that the new one would be in the chart for the new cert period. We tried to explain that we follow the most up to date orders. They family wouldn't have it and said that's why the nurses were doing things wrong. It was actually the family doing things wrong...like increasing humidification and saying they were increasing the O2...that's after teaching the family too!

JustBeachyNurse, LPN · Mar 17, 2014

Would you believe some Dr's dont give parameters?
i had to go through a lot of hoops to get this 1 doc to write parameters for albuterol.
He just gives orders that say" give albuterol q 4 hrs prn".

This is not uncommon. It is more frustrating when a coworker accepts such an order and other nurses or clinical supervisor must chase down & f/u with physician to get clarification and complete order.

The worst I saw was

"Increase neb tx. to QID"

What was more frightening/sadder the nurse that took the verbal order couldn't see what the issue was...and the patient had 2 different neb orders that could be given QID around the clock or PRN. She later freaked when the order was rewritten as "clarification received by Dr. X, d/c "increase neb tx to QID" start "albuterol 1.25mg/3mL give 1 vial via HFN q4h PRN cough, wheeze, dyspnea, increased work of breathing. "

KATRN78 · Mar 18, 2014

I was so flipping mad, someone making marks for the shift I worked. I told the clinical manager. This nurse also was making circles for prn meds that I did not give on my shift. Mom likes to play Doctor and say "give albuterol q 4 hour tonight". I won't give a prn unless kiddo meets the requirements I.e. "give as needed for wheezing" . Mom knows I won't. Nurse makes circles for my shift. Annoying!

JustBeachyNurse, LPN · Mar 18, 2014

Circling PRN is not standard as they are PRN not scheduled. She/he has issues.

brillohead, ADN, RN · Mar 20, 2014

OMG, I would so TOTALLY flip out on someone if they did that! :mad: