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????

[morte, LPN, LVN]

do you have any sense that this nurse (in the OP) is being truthful, or is she lying ? it would seem the logical thing to do would be to write a shift end note, or if tabs are on a check off, do that at shifts end....then it will be documented that somewhere in the last hour or so of the shift the tabs was on......and the woman whose husband was noting when she didnt have her call bell and alarm on.......if she was able to use the phone, i have NO doubt she was able to take off alarm and toss the call bell were she couldnt reach it.....again end of shift doc. and fasten the call bell in such a way that she cant undo it.....

[David13, MSN, RN]

I think the question is SHOULD nurses chart on these types of situations. My thought is that if a nurse comes on duty and finds a patient in a situation that could potentially lead to the patient's harm, he or she should definitely document it. This documentation should probably take the form of an incident report that does not become a part of the member's chart. This is the nurse's way of protecting her/himself from liability and also assists (hopefully) in preventing future occurences by alerting risk management to the possible need for a process change.

If the situation is something like a resident being found in their day clothes vs. their night clothes, my thought is that the situation is best discussed on a professional level between the nurses, particularly if this is a routine occurrence. Making a note in the chart about these types of situations is, in my opinion, merely an attempt to get someone "into trouble" and an attempt to make the nurse charting it look better by comparison.

[Straydandelion]

A potentially dangerous situation that would affect patient outcome should be documented in an incident report. Other situations should be simply documented "cleaned patient's soiled diapers on first round" can be in nurses notes. However if the diapers of a lot of patients not changed, or some indication that it had been awhile since the patient had been changed, this would be the "running notes" discussed in other threads that you can just keep for yourself and talk to the charge/nurse manager if becomes a regular occurance.

[diane227, LPN, RN]

This is not good charting and this should be brought to the attention of the manager. If she has a bone to pick with someone she should do an incident report. Placing such minor information into the medical record is inappropriate. She must have a lot of free time on her hands.