A question regarding charting

I would definitely chart accurately what I assessed even if it differs from previous nurses' assessments. As far as the incorrectly documented information: if you know the person who charted it, you could nicely mention it to them and that way they could go back in the chart and correct it. I would want someone to tell me if I charted something grossly incorrect. I think it happens b/c sometimes people are charting under pressure while being interrupted frequently. Also, speed seems to be valued above all else but speed can sometimes make it easier to get into autopilot mode where the brain gets a bit disengaged from the fingers entering the data. Erroneous information ensues. (i.e., the BKA w/ normal pedal pulses).

Bottom line: chart what YOU assess.

Chart what you see..."Foley catheter present, draining clear yellow urine..." even if the previous shift charted "no Foley." "Patient has Rt. BKA. Skin on stump intact." If this differs from what the previous shift(s) wrote, than the reader will have to determine if that is incorrect.

And, FYI, you can hear faint breath sounds on the side of a pneumonectomy d/t transmission of the sounds from the side with a lung.

If the charting was blatantly wrong/impossible (such as with pedal pulses on the side of a BKA), then I would bring it to the attention of that nurse--in a nonthreatening manner of course--the next time they are there. The ball is then in their court. If incorrect charting turned into a rampant issue, then I would say something to the NM or the unit educator. At the end of the day, you yourself cannot not change the issue alone--it is those nurses who are charting erroneously (and the NM and other leadership positions on the unit) who are assuming the risks. At that point, just make sure you own charting is accurate.

Do not ever, ever, ever continue erroneous information just because everybody else did. I review charts for a living, and when I see somebody who's been turned q2h for days and then suddenly has a Stage 2-3 pressure ulcer the next shift after she gets transferred to another floor, or who haas been taking 75% of her regular meals in the days after she stroked out and went to the ICU comatose, I know the standards on the first floor were lax. With electronic charting it's particularly easy to just continue the prior documentation, but this way lies madness (and litigation).

Bad charting is a lie, and lying in charts is a crime. In many cases, billing is based on hours of care, and if care is charted but not done, that's Medicare/Medicaid/insurance fraud. At very least it leads to bad care, if someone relies upon it; at worst, it could lead to death. Somewhere in between there is the chance that you will be called to explain in deposition why your chart is so much different from the ones before it. Believe me, if you can say, "That was my assessment, and it's accurate," you are in a much better position than the people from the previous shifts who will have to explain themselves as to why they saw no such thing.

Thanks everyone! I had two of these patients and charted what I assessed (never a question in my mind to chart otherwise). The two of us who had these three patients said something to our instructor about it, I don't know if she took the information further than the room we were in. Our instructor was a total stickler about documentation (a good thing!) and really drove it into our heads that our documentation is our legal document of care, and it should be stellar. I was just wondering if you should ever say something to the person who documented erroneously in the real world (AKA, the non-student world).

Thanks for your insight! :)

Our instructor was a total stickler about documentation (a good thing!) and really drove it into our heads that our documentation is our legal document of care, and it should be stellar. I was just wondering if you should ever say something to the person who documented erroneously in the real world (AKA, the non-student world).

And the truth (in your documentation) will set you free if the you-know-what intersects with a spinning fan blade.

Re: talking to another nurse about his/her documentation (or lack there of…or the erroneous nature of it)--I would. Something like "this may have been a simple type-o [even if you know it isn't ), but you charted that pedal pulses were palpable on their foot that was previously amputated." That way it is a nice, non-threatening way to point this out to them.

It's appropriate for your instructor to speak to the nurse manager about this sort of thing, so students and staff don't get into conflicts. The staff are not your peers. You did the right thing by speaking to her.

Re: talking to another nurse about his/her documentation (or lack there of…or the erroneous nature of it)--I would.

Just for clarification, I mean once you are an RN then you can speak to another nurse about his/her documentation. As a student, I agree, you should go through you instructor and let the deal with it.