Am I reading too much into this?

[Pepper The Cat, BSN, RN]

Got a question for everyone - I'd really like some unbiased opinions.

First, back ground info: We do computerized charting, including shift report. Shift report is pretty much all done via the computerized charting and is therefore part of the chart. You can go way back and read shift reports from weeks back if you want.

So yesterday (Friday) part of my shift report was: Pt very tired today, states he did not sleep well due to roommate.

That was all I wrote about that.

I came in this am and read the report from nights.

It said (paraphrased) : Pt complained to Day Nurse that he did not sleep well last night. Pt was observed in bed with eyes shut. Pt was checked every hour and appeared to be sleeping. Pt was changed and did not complain of not sleeping.

There was more details than this, but you get my drift.

Basically, to me it came off as very defensive.

I never accussed the night shift of anything. I just stated that the pt stated he did not sleep well.

Just for the record, his roommate's report for the night the pt said he did not sleep well stated that the pt was using call bell frequently and yelling for the nurse.

What's everyone take on this? Am I reading too much into this, or is this nurse coming off as defensive towards me? :uhoh21:

I certainly did not accuse them of anything. All I said was the pt said he was tired!

[SuesquatchRN, BSN, RN]

Who cares? Seriously. The notes for both patients jibe. And it would be astonishingly unprofessional of her to snipe at you in a legal document.

Fugedaboudid!

[Bortaz, MSN, RN]

Two questions:

1. Why would the other nurse question a report of subjective information?

2. Why would you care what she thinks?

Mountain out of a molehill, IMO.

[NursKris82]

My 2 cents- I think so.

[RedhairedNurse, BSN, RN]

What came to my mind when reading your post is this.....when a nurse charts, it really isn't necessary to use the word pt in every sentence. The chart is about the pt. Sorry if I'm off topic.

I would have written it this way:

States to be very tired today, states he did not sleep well due to roommate. complained to Day Nurse that he did not sleep well last night. was observed in bed with eyes shut. was checked every hour and appeared to be sleeping.

[blondy2061h, MSN, RN]

Yep, you're reading too much into it. You charted that the patient complained he didn't sleep well. Other nurse charted that the patient appeared to be sleeping. I don't see the problem. You both charted what you know.

[caliotter3]

I believe that the other nurse was being defensive in response to your report but it does not matter. I've encountered this type of charting/reporting often. One person reports somethig objective, and the other nurse(s) have to pounce on it because they take it as a personal attack. Or they want to discredit the observation of the original report or the nurse who made that report. Almost always based on childishness. Rarely an objective reporting of facts as follow up. Don't get upset about it. If you do, then you have bought in to the other nurse's true motives. I doubt s/he is concerned with how well the patient slept.

[Roy Fokker, BSN, RN]

Reading too much into it.

cheers,

[RNsRWe, ASN, RN]

Both reports addressed the situation. I did not see hers as defensive, nor yours as accusatory.

Why you are reading it as more I can't guess...let it go.

[lpnflorida]

I do not feel the following nurses documentation was defensive. If a patient is not sleeping well, it is important to address that. That was what the following nurse was doing charting what she observed on her shift which was not a reflection on your charting which concerned an entirely different night in which the patient stated they slept poorly.

[Meriwhen, ASN, BSN, MSN, RN]

Sounds like night nurse had a case of the "CYA" jitters: maybe she's (he's) new and/or nervous about her job, and felt like she had to respond the way she did.

That being said, I think you're reading too much into it: you're documenting the facts, and so is she. Continue documenting whatever you see fit to document--if's there's a problem, I'm sure your NM or someone in charge will say something to you.

And don't worry about what night nurse is documenting--the NM will deal with her if she thinks there's a problem there.

[lpnflorida]

I once had a doctor who brought up the fact that his patient told him he was not sleeping at night. The doctor then said how come no one has documented if they are or aren't sleeping?

Both of the nurses are correct in what they are documenting.