Charting Shame

Updated:   Published

I have found this group to be very therapeutic and help through so much stuff. I know in nursing school and even in starting a job we have learned behaviors. It doesn’t mean it’s right, but it’s what is done. Something I have found I have thought about is with my first patient event. I have talked about this before so read previous posts for the full story. 

Anyway long story short, I keep circling back to repetitive thoughts and shame.
This is because when I first attempted to take my patients blood pressure after an obscure automatic reading, I had attempted multiple times to take a manual blood pressure, but could not even focus. So when I go back to put in my charting I documented it was in range being unsure if it was, as well as the medication 15 minutes later than what was administered to keep it in time frame. Well after I did that and still watched my patient, it didn’t sit with me. I felt so ashamed. I go back within 30 minutes of it all and get all correct and current vitals. I enter them in the system. This did bring a relief but I did not want to delete previous information as it would look suspicious. I know the vitals I entered had to be close  because of the trend but still just makes me feel ashamed to admit as a nurse. I know when I went to go talk with my manger, I couldn’t get all the words out to tell her but she understood what I was trying to say. She said, you have punished yourself more than what I ever could. Learn and grow from it. 

To this day, everything in the chart is documented as accurate as possible. I know I have witnessed many nurses falsely document or not even document at all. I know that doesn’t make it right, but again a learned behavior. Learn from your mistakes. Be kind to yourself. Admit your wrongdoings. Similar situations? 

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

It sounds like you learned a lesson and it was an instance where nothing bad happened to your patient. Be kind to yourself. We are so inundated with charting details that sometimes things can slip through. I know that when there are 16 entries for where the patient has edema, I haven't specifically gone back to assess the ankles vs feet vs legs for moderate, mild or trace. Sometimes I'll just lump it all together, or even just skip it. One blood pressure reading, when there are normal reading before and after, is not a big deal. Patient position, movement, cuff position, all of these things can affect a single reading. Don't worry about it. 

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Yikes, yea don’t beat yourself up it’s done, but one thing tho, you don’t want to give meds without being sure about those vitals.

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Specializes in Geriatrics, Dialysis.

Not funny yet kind of funny charting oops! I have seen in the SNF I used to work for. A gentleman on neuro checks post fall who was consistently charted as having pupils equal and responsive...kind of impossible as he had a glass eye.  Another man who always seemed to have clear lung sounds throughout despite having had a lobectomy, amazing how that works! 

My all time favorite though was back in the days of paper charting, everybody just kept checking the same boxes and writing the same thing as the previous person who charted. The huge paper charting binder was not cleaned up in a timely manner. This resulted in a woman who had miraculously  consumed 100% of all meals for 3 days after she had died before it was caught. 

Nurses are not the only guilty party either. I can't tell you how many provider notes I read with details of an assessment that somehow was magically performed from the doorway or even the hall outside the residents room. 

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Specializes in Med-Surg, Geriatrics, Wound Care.

Being a wound care nurse, I find documentation by providers saying stuff like skin is "pink" (on an African American with wounds).  No rashes/lesions (again, rashes or lesions on the person). Some are adding to 'areas seen'. And of course the ER nurses that chart skin as "intact" (despite admitting wounds). The normal stuff.   Pulses on amputees. Or the days of charting "dressing covering site" (nobody changed the dressing??!!??)

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1 hour ago, kbrn2002 said:

Not funny yet kind of funny charting oops! I have seen in the SNF I used to work for. A gentleman on neuro checks post fall who was consistently charted as having pupils equal and responsive...kind of impossible as he had a glass eye.  Another man who always seemed to have clear lung sounds throughout despite having had a lobectomy, amazing how that works! 

My all time favorite though was back in the days of paper charting, everybody just kept checking the same boxes and writing the same thing as the previous person who charted. The huge paper charting binder was not cleaned up in a timely manner. This resulted in a woman who had miraculously  consumed 100% of all meals for 3 days after she had died before it was caught. 

Nurses are not the only guilty party either. I can't tell you how many provider notes I read with details of an assessment that somehow was magically performed from the doorway or even the hall outside the residents room. 

LOL! Yes this, ha ha! You forgot the pedal pulses with the bka 

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2 hours ago, CalicoKitty said:

Being a wound care nurse, I find documentation by providers saying stuff like skin is "pink" (on an African American with wounds).  No rashes/lesions (again, rashes or lesions on the person). 

I’ve seen the opposite, I’ve seen some constantly charting AA as dusky. I’m like huh? 

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