can nurses chart about this kind of things?

[Ms.RN]

i read a charting of resident from a nurse who works after my shift. she wrote down such a things like, at the beginning of a shift patient was still dressed in cloth so she did this and this. whenever i read her charting, she alwasy chart about what she saw at the beginning of the shift, patient didnt have tab alarm on etc, sounding like she wants to either prove that she is better than everbody else or she wants to get other nurse into problem. i mean what if family decides to sue the facility not necessarily related to charting and her lawyer read all the stuff she wrote down? can this kind of things can be charted? okay so if patient is still not changed to gown or whatever, cant she just change resident to gown instead of writing down in chart, which becomes a lagal document that a nurse from previous shift neglected a patient? doesnt nurse have to chart on things that are problematic like patient c/o pain, sob????

[Virgo_RN, BSN, RN]

Patient neglect, such as failing to provide hygiene and failing to protect the patient from harm (by neglecting to put the tab alarm on, for example) would be Incident Reports.

[caliotter3]

This person is not a team player and by bringing attention to discrepancies instead of correcting the discrepancy and verbally discussing with supervisors or the other nurse, she is asking for trouble. I am surprised that administration has not had a talk with her about her charting.

[corky1272RN]

Sometimes charting what you find helps "relieve" you of blame from a situation left by previous nurse. Such as "found pt on floor" or "went to assess pt, found IV out" or something like that. But if the nurse is always putting in "minor" things such as "pt still in nightclothes at 1200" that may be a little much.

[leslie :-D]

Patient neglect, such as failing to provide hygiene and failing to protect the patient from harm (by neglecting to put the tab alarm on, for example) would be Incident Reports.

i agree but i think we'd be hard pressed to find a source that definitely states what should/shouldn't be noted.

i've read sources that explain how to chart but never one that explains what to chart or not.

that said, if i came onto shift, observing incidents that could possible implicate me down the road, why wouldn't i want to note something that demonstrates me being proactive, vs continuing in being negligent?

what if pt sustains serious injury r/t alarms not being on, and family sues?

they'll be studying those notes w/a fine-toothed comb.

and i'll be darned if i'm going to be charged in an event because i didn't note otherwise.

see what i'm saying?

leslie

[Batman24]

This person is not a team player and by bringing attention to discrepancies instead of correcting the discrepancy and verbally discussing with supervisors or the other nurse, she is asking for trouble. I am surprised that administration has not had a talk with her about her charting.

I would think they'd talk to her as well. I'd bring this to management's attention at once as this should be discussed. If something like patient neglect truly needs to be addressed she will be advised to do Incident Reports as needed. When people complain about every little thing I tend to think they are just looking for trouble and to pin blame elsewhere even if it is to cover for themselves. She could be digging herself a nice grave here along with her co-workers in a lawsuit. I'd talk to your superior at once.

[SunnyAndrsn]

The types of things you are describing would not be things I would include in charting, unless its to describe the patient's desires. For example, we have a resident who learned how to remove their tab alarm, which I would chart as "Staff observed resident removing tab alarm, pressure pad alarm in w/c for safety, will monitor to evaluate efficacy of new alarm."

Or for residents who WANT to stay in pj's I may chart it, just so everyone is aware it's not a negelct situation, but rather what the resident wanted. "Per resident request, resident remains in nightclothes. Peri care and AM hygiene performed." Answers a lot of questions for family members, and in case neglect is called into question, this type of charting can help.

What gets on my nerves, at my home care job, is a nurse who charts not on pulmonary status but on what the kiddo watched/did during the day. "Pt. up and awake watching the Bad News Bears, seemed to enjoy it." Yet she documented crackles to upper lung fields on the flow sheets--nothing in the narrative note. Drives me batty!

We have another nurse, English is not her first language, and it is very difficult to understand her narrative notes. But that's a whole other issue.

[SunnyAndrsn]

I would think they'd talk to her as well. I'd bring this to management's attention at once as this should be discussed. If something like patient neglect truly needs to be addressed she will be advised to do Incident Reports as needed. When people complain about every little thing I tend to think they are just looking for trouble and to pin blame elsewhere even if it is to cover for themselves. She could be digging herself a nice grave here along with her co-workers in a lawsuit. I'd talk to your superior at once.

I agree, this is just not a good idea!

If she has issues with how cares are being performed, then it's an issue to address internally--with CNA's and the nurses.

[Virgo_RN, BSN, RN]

Yes, I agree, Leslie. I don't make a habit of charting nitpicky little things that the previous shift may have overlooked, but I have been known to chart things that I felt were significant enough to warrant covering my own behind.

[MikeyBSN]

This is a sticky issue, and I disagree slightly with some of the general consensus on the issue. The patient chart is a medical record. Therefore, only things that are pertinent to the medical care of the patient should be in the medical record. However, there are some things that may be pertinent to that patient's care that are unrelated to the basic complaints of the patient. For example, I document every time I change a patient, every time I feed them (even if they don't have DM and are not on I and O's). I came in one day and found a pt restrained in his clothing and I had to document it because I need to have security release the restraints, then I needed to do a valuables check on the pt. The other day I documented that I called upstairs for a regular hospital bed for an obese patient. Did that absolutely have to be in the medical record? Probably not, but it went to patient comfort and the prevention of pressure ulcers. Before documeting, I ask myself "does this effect patient care?"

I did have a situation once where a patient needed to go to the OR and the surgery team was in the OR with another patient. We waited a long time for the back-up team to arrive. I didn't write "back-up team was late and pt didn't go to the OR until 12." I simply documented my care until that point. Then when the surgeon came I documented that the surgeon was evaluating the pt, then I documented time to the OR. This doesn't "hang" the person, but if the chart goes to court, it doesn't look like you just sat by and didn't send the pt to the OR in a timely fashion.

[Virgo_RN, BSN, RN]

Agreed. I wouldn't chart "Day shift nurse neglected to position patient for comfort, am care not done, moaning in pain" or "Standing in middle of room, IV DCd and site bleeding, day shift forgot to put tab alarm on." Instead I might describe what the patient looked like when I walked into that room for my initial head to toe assessment. That might include the fact that the patient was soiled and painful, or that they had gotten up and DCd their IV and the tab alarm was not attached to their gown, and what I did to remedy those problems. Pain control, factors affecting skin integrity, and measures taken to prevent falls are all pertinent nursing information, and are therefore appropriate to chart on. I don't have to point my finger at the previous nurse who may have overlooked these things, but can simply describe what the patient looked like when I walked into the room, and what I did to fix it.

[lpnflorida]

If I started a shift and found a tabs alarm not on a patient who was suppose to have one. I might chart that patient observed with tabs alarm off on first rounds. Why? Let me give this as my reason. Just last week a family member on our unit, complained about this very thing to management. He had documented on paper the number of times when he came to visit that he wife did not have a tabs on, the number of times he found that call light was not attached to his wife. He also had documented when his wife had called him on the phone stating that no one had changed her etc. Fortunately for many of the things his wife had told him, it had been documented her refusal to change either into or out of clothes, I had been documented when a prn pain med had been offered but refused. Sadly as to why he found her without a tabs or call light with in reach, we had no defense, as it was not documented .

Now, I also start my shift document tabs on patient, call light attached to patients clothing. Sometimes we do what we have to do to protect ourselves and our patients. It is not meant to get anyone in trouble at all, It is to keep us all out of trouble. If more people documented as such, I believe we would find less incidences of patient in soiled clothing, or not having tabs on etc. We do need to be aware of these things.