Charting behaviors

Yes definitely I would, and tell your manager.

Definitely and make sure that your manager or DON know about this. Who knows what she has taken while out too.

Admin told nurse on duty not to chart any of it. She was gonna chart it bUT when she called Admin and DON she was told not to. Just to get witness statements from the family member who destroyed the drugs at the facility.

She definitely needs to chart exactly what occurred. Otherwise, she is setting herself up for potential problems. Remember, if something comes up later she will not be able to prove that management told her not to chart the details. Also remember they will happily throw her under the bus to protect themselves if need be. Always, always chart exactly what happened in such situations. That is the only way to protect the license we have all worked soo hard for.

I have sometimes made my DON and administrator unhappy d/t thorough charting of behaviors. My first job out of nursing school was as a psych nurse, and there you really, really learn to CYA. As the others have said--always chart. Be deliberate with your charting, noting carefully what family said about the resident and what the resident actually said or did in your hearing/sight. For example: family member tells you that patient A threatened to harm himself. In your charting, state that specifically: "Bob Smith, resident's brother, states that patient A threatened to elope and run into the street. Patient A has not made any such statements to staff or within staff's hearing. DON (name), administrator (name) have been notified via phone call/fax/text/etc." Factual and clean of emotion/opinion.

Absolutely