Charting

[rentalnurse, RN]

Just a question and didn't see another topic on this. At work the other night I received report on a patient that was just admitted 1730 and I come in at 1900 the nurse was still working on the admission paperwork. About 1940 she handed me the chart and left. I did my assessmnet on the patient and noticed that the nurse wrote at 1800 'see admission assessment'. I looked at the admission sheet and the first 2 pages were done, page 3 the assessment part was blank and then the back page was done. I told my charge nurse about it and he said to fill it out. I stated since it was timed 1730 and I was not there that I couldn't. Of course I was written up for 'disobeying the charge nurse' I don't feel that I was wrong in not filling it out. Any suggestions?

[meandragonbrett]

1--The charge needs to get over himself. I'm so sick of people writing each other up over petty BS.

2--I wouldn't have filled it out

[Chisca, RN]

Since he has gone to the trouble of putting in writing I would talk to your supervisor about it. What exactly is on page three of the assessment? If it were social data and I had time I would have filled it out as a courtesy to the other nurse. If it were physical assessment then I would have left a note for the nurse who did the assessment. The charge nurse made too big a deal about it but you brought the problem to him. Next time I would leave him out of the loop. It should have been no more than telling that nurse "hey, you forget to fill out page 3" the next time you saw her.

[rentalnurse, RN]

Thanks guys,it was the physical assessment that was left. I've only got 3 shifts left till my contract is up. I will double check everything till then since they are reading all my charts i guess.

[caliotter3]

Thanks guys,it was the physical assessment that was left. I've only got 3 shifts left till my contract is up. I will double check everything till then since they are reading all my charts i guess.

Yes. It is always best to cover oneself, especially after a writeup, and knowing you are soon to be gone, but still an easy target. I would have just left a note to the other nurse. Your charge nurse overreacted.