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Discussion

Charting

I have a small problem..... I work in a state prison. Its God aweful. Been there over a year. I am a competent, consciencious nurse for over 30 years. In a fit of anger one day I put a nurses name in my nursing notes. I know its subjective. What are the ramifications. She ignored a chest pain. I need help on this one. I am being the scapegoat. All I wrote is that Nurse" soandso" came on block and said she was at lunch and told me to do the assessment and left.My problem with this is that whomever takes the call in medical, is supposed to follow thru with the assessment etc....and since when is lunch more important than a chest pain? I was seeing a dental emergency! Now I am getting nailed for not immediately seeing the inmate AND using subjective charting! Sending out an S.O.S

Thank you my fellow Nurses!!! HELP!!!

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    Hmm - I am not at all familiar with correctional nursing protocols. But, I would think that information about the way you were alerted to the patient situation (time, method) would be relevant. Maybe if you had charted "notified by SuzieQ RN" - putting in the bit about her being at lunch was probably a no-no because it was not relevant.

    BTW, none of what you wrote was "subjective" it was all factual.

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