Altered charting

nurjco · Mar 19, 2004

:stone Hi I am new to this forum and I have come across a situation at work that I wanted to get more input on. Here's the situation: I had to give pt. 2 units of PRBC's. I did the pre vitals and they were all fine. Including a normal temp of 98.8 orally. 15 min. vitals were also normal. I then was ending my shift and passed this patient on to another RN to finish the transfusion and also complete the next. When I came back to work the next day it was reported to me that the pt had become confused in the night. I happened to glance at the blood vitals with the transfusions and noted that my charting of the temp had been altered to include 98.8 AX and that the post transfusion temp was 100.9 Ax and the box next to the transfusion reaction was check marked as None. I notified my supervisor of the change and made her a copy. I am not sure what will happen next with this particular nurse, if anything and am wondering what you all feel the appropriate steps should be for her. This nurse is notoriously known on our floor as being able to get away with A LOT. I would like to be prepared. Thank you.

gwenith, BSN, RN · Mar 19, 2004

If she is notorious for getting away with a lot then probably nothing will happen you however have to keep in mind that you might have made an enemy and sorry to repeat this but

document document document

keep running notes of conversations with her and issues. Could be that she will do nothing and that she was "trying you on" to see if she COULD get away with anything. Sometimes too the reaction you get is not immediated - it is two or three weeks down the track when you feel the knife in your back.

Good luck and keep us posted - a lot of people here have been through situations with difficult co-worker so you usually can get some advice on how to deal with them.

gwenith, BSN, RN · Mar 19, 2004

If she is notorious for getting away with a lot then probably nothing will happen you however have to keep in mind that you might have made an enemy and sorry to repeat this but

document document document

keep running notes of conversations with her and issues. Could be that she will do nothing and that she was "trying you on" to see if she COULD get away with anything. Sometimes too the reaction you get is not immediated - it is two or three weeks down the track when you feel the knife in your back.

Good luck and keep us posted - a lot of people here have been through situations with difficult co-worker so you usually can get some advice on how to deal with them.

sharann, BSN, RN · Mar 20, 2004

So does this mean that by altering it, she was avoiding dealing with a serious reaction to the blood? I hope not for her patients sake. You did the right thing by reporting this.

sharann, BSN, RN · Mar 20, 2004

So does this mean that by altering it, she was avoiding dealing with a serious reaction to the blood? I hope not for her patients sake. You did the right thing by reporting this.

nurjco · Mar 20, 2004

I believe this is exactly what was happening. It meant less work for her by altering the charting.

So does this mean that by altering it, she was avoiding dealing with a serious reaction to the blood? I hope not for her patients sake. You did the right thing by reporting this.

nurjco · Mar 20, 2004

I believe this is exactly what was happening. It meant less work for her by altering the charting.

So does this mean that by altering it, she was avoiding dealing with a serious reaction to the blood? I hope not for her patients sake. You did the right thing by reporting this.

luanne123 · Mar 20, 2004

I would contact the hospital attorney.

luanne123 · Mar 20, 2004

I would contact the hospital attorney.

redwinggirlie · Mar 20, 2004

I copy the transfusion documents and have the charge nurse initial them. Mostly, they end up shoved in the depths of my locker, but I know they are there. Good luck to you.

redwinggirlie · Mar 20, 2004

I copy the transfusion documents and have the charge nurse initial them. Mostly, they end up shoved in the depths of my locker, but I know they are there. Good luck to you.