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Discussion

Am I documenting this right? Or is my supervisor right?

I'm on week three of my first nursing job. Since I'm still on orientation my nursing supervisor still has to approve all of my nurses notes before i sign them. I'm getting really frustrated because she keeps asking me to take out stuff that I observe. For instance "Pt. had a bruit caused by her 60% Ejaction Fracture." And "Rales in the lower lungs" and "irregular heart rate". She says that if I say that something is wrong I also have to say what I did about it. Like, did I call the doctor? Did I have her cough and then check her lungs again?" What did you do?? I understand that she's teaching me to cover my butt for future law suits. But, what is the point of documenting if I only put the normal stuff and leave out all the (interesting) stuff?!?!

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    • Experts

    Your supervisor is correct. If you observe something that is not "normal" and document it, you also have to document what you did about it. Otherwise, you are most definitely providing the information needed for lawsuits and criticism.

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    I agree with your supervisor. You are documenting and almost diagnosing in your notes. ex. irregular heartrate. Just document what the heartrate was.There is no reason to mention 60% ejection fracture. Its in the report.Also about the lung sounds, if the patients lung sounds are not clear, there needs to be an intervention.ie. Breathing tx, incentive spiromentor, inhaler. Keep it simple.

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    • Experts

    If you are three weeks into your first nursing job and your supervisor tells you something you are doing is incorrect, you should take her advice and learn what you can. You are new, she is trying to help.

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    Have you ever heard of SBAR? It is a good tool for documenting. You should look it up.

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    I'm having a hard time understanding exactly what you're trying to describe. What setting do you work in?

    How do you know the EF? Did you do an echo? Was one performed recently? Are findings such as those you listed changes from the patients' prior (documented) status?

    I don't think your supervisor is trying to get you to omit important findings; she seems to be trying to get you to do something about them and then document appropriately. Also be careful to only document things that are evident.

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    i am going to have to disagree with the general consensus here...i do agree with not charting about the ej fraction. it may be documented in the h & p but that is just going about the call of duty..

    irregular heartbeat and lung sounds are what they are...nurses assess these things all the time and it is within the scope of practice for a nurse to determine these things and chart them. irregular heart beat can result from a mountains of diagnosis. the doctor may be long aware of these things and the have been documented over and over by physicians.....i work in a ltach where people come in for pulmonary rehab...jeeezzzee if i called the doctor every time i heard rales (unless combined with some other kind of symptom causing a acute change) id get fired....people are in the hospital and they are sick....does her boss expect everyone to be well so there is nothing to chart....what i don't understand here is why her boss wants her to lie in her charting...i mean it is what it is .... from the previous post it sounds like most of the people here agree with changing the charting and documenting something that is incorrect with the patient.....

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    • Guides
    I'm on week three of my first nursing job. Since I'm still on orientation my nursing supervisor still has to approve all of my nurses notes before i sign them. I'm getting really frustrated because she keeps asking me to take out stuff that I observe. For instance "Pt. had a bruit caused by her 60% Ejaction Fracture."

    I always thought that was "ejection fraction"--- but I could be wrong and very often I am!

    If the bruit is included in the doctor's history and physical findings, you wouldn't need to write that out as "caused by" because it it doesn't provide any new information that is in addition to what is already in the chart, and you're using a flow sheet to do your assessment where you would note those expected abnormalities not out of the ordinary based on the medical history.

    If it is a new finding you definately have to document what you did about it. Sounds to me like she's trying to get you to critical think so you can function independently, lawsuit fear is part of it for sure, but not all.

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    • Author

    Thanks everyone for the replies...

    Nursel56, you're right. It is fraction.

    I agree that making the connection between the bruit I heard and the ejaction fraction already diagnosed by the doctor was probably taking it a step too far.

    One of you was asking what the setting is... It's a long term care center.

    SB2010.. I'm definitely just doing what my supervisor says, for now. The things she's right about I'll do though eternity. The things she's wrong about though, I'm going to toss.

    TexasspadequeenRN... Glad you chimed in. You expressed my thoughts. I mean... observing those things. It's within our realm of practice.

    I guess, it's a balancing act between covering my butt and documenting what I see. I think the key is to document this stuff upon admission so that when I assess it it isn't a new finding. Does that sound right to people? If it isn't documented upon admission then I have to show that I did something about it, huh? Even though the three issues I mentioned were clearly chronic problems. Or if I put the word "chronic" before it would that help cover my butt? Or not, since I'd probably have to prove that with medical records if it ever went to court. Ugh, this nursing thing is so confusing!!!!!

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    • Experts

    Well, I've never worked in LTC, but one of the great "pearls of wisdom" that was drummed into us in my nursing school long, long ago was "Never document a problem in a chart without also documenting what you did about it." (Does your facility use the "charting by exception" model? If that's the case, then one wouldn't document what's "normal" for a particular client (i.e., chronic rales or irr heart rate)).

    I agree that, if you're documenting a problem that other people aren't documenting and not documenting that you took some action to address that problem, you're creating a sticky situation for yourself if there were ever a reason for an attorney to review that chart.

    Of course, maybe part of the answer here is for the rest of the nursing staff to step up their documentation. :)

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