Published Jul 7, 2004
At the clinic where I work, I'm the only 3/4 time nurse. All others are full time.
Often, when I come back from a few days off, I'll be charting on a pt and notice that no one has been charting on them except for me.
We have pts who crash, get serious infections, get a lot of new orders, etc.
Recently, several pts have crashed. I looked in their charts several days later and saw that nothing had been charted about it.
Whenever I'm involved in or observe anything unusal, I chart it.
Recently, I've assisted others when their pts have crashed, vomited, had a blood loss, etc. And no one has charted on it. I've kinda been charting for other people in these situations. For example, I'll chart after the fact something like "I observed Nurse X administer 0.4mg nitroglycerin sl at 1314, 1319 cp was not relieved, V/S blah blah blah. Another dose of nitro 0.4mg sl was given by nurse X at 1319. I obtained a pulse ox reading of 90% at 1321, glucometer reading of 198 obtained at 1325...."
In other words, I've been charting as observing the actions of others, since they're not charting it themselves.
A couple weeks ago, I opened a pt's chart and saw that I'm the only person who has charted on her at all since Feb. I know this pt has had blood losses, chest pain, etc. on days I've been off and no one has charted it.
My bosses haven't said anything.
Any of you nurses experience stuff like this?
What do you think?
Spidey's mom, ADN, BSN, RN
Wow, that is amazing. I've come across the stray nurse who in a very busy 12 hour shift forgot to do an assessment and chart. But that is rare.
Sounds like your managers aren't doing a good job at checking charts. I can't believe no one charts. We get notes all the time about forgetting to put in a care plan or not filling out the dietary sheet or leaving a blank on the initial assessment. But what you are describing needs to be discussed with someone higher up.
meownsmile, BSN, RN
I think charting like you are doing if fine as long as all you chart is what you observe or did. But im sure if you are only assisting them in a siutation there is much more they should be charting from before and after the initial crisis.
Definatly bring it to the attention of administration or whomever you report to, take the chart to them and express your concern and let them do the chart review. Then let it drop, dont discuss it with anyone else. They have the scheduling/assignments as to who was responsible for the patients when and they can go have the charting corrected. If they dont its administration and/or the nurse in charge of the patient that has to answer to why it wasnt updated and corrected. At least documentation of actions during your presence will be up to date and correct. It may save you a court date later. But then im sure they'll ask you to cover for someone else while they go to court to answer to the holes in their charting ey? Go figure.
As far as no charting since Feb. well im sure someone will have to answer to that when the state or JC comes in. At least your covered, you cant control the lack of follow through from others.
All I have to say is that it's REALLY scary!!!
Hasn't anything been brought up by mgt. about this???
Hellllllo Nurse, BSN, RN
Mgmt has not said anything. I really don't know if they have noticed it. I only chart what I have done, assisted with and directly observed when I am not the charge nurse. When I am the charge nurse, I have charted on things that were verbally reported to me by other nurses.
As for whatever happens when I'm off, oh well! I can't be responsible.
My boss has been completey stressed out lately. We don't report off to anybody. We are a clinic. There is no "chain of command" pe se. There are only three people over me at the entire facility. I don't see any of them very often, and don't really know them very well.
When I am charge, I feel fine asking a co-worker "Will you chart on that?"
When I'm charge, I chart on just about everything that happens anyway, even if it's something that was reported to me, but that I did not directly observe, for example: "Nurse X reported to me that pt X c/o nausea, B/P dropped from baseline of blah to blah, XX interventions were perfomed by nurse X, according to her report to me. I assessed pt at XX time and found him to be in no acute distress, V/S XXX. Pt reported nausea resolved."
But when I'm not charge, I feel I'd be over-stepping if I instructed someone else to chart.
Definatly bring it to the attention of administration or whomever you report to, take the chart to them and express your concern and let them do the chart review. Then let it drop, dont discuss it with anyone else. They have the scheduling/assignments as to who was responsible for the patients when and they can go have the charting corrected. If they dont its administration and/or the nurse in charge of the patient that has to answer to why it wasnt updated and corrected. At least documentation of actions during your presence will be up to date and correct. It may save you a court date later. But then im sure they'll ask you to cover for someone else while they go to court to answer to the holes in their charting ey? Go figure.As far as no charting since Feb. well im sure someone will have to answer to that when the state or JC comes in. At least your covered, you cant control the lack of follow through from others.
I think you're right, meownsmile. I think I'll just bring a chart to my boss, mention something that happened w/ a pt and tell her that I've noticed there have been some "clinical variances" that haven't been charted on.
I will not push it after that. My behind will be covered, and it's the boss' responsibilty from then on.
I ran into this type of problem a couple of years back when I was a nurse consultant. The primary LPN of an adult day care center never charted a single occurrance on any pt. She had worked there for years, and each pt just had a brief monthly note stating V/S and attendance.
She left soon after I started, and I stressed the importance of charting w/ her replacement, and there wasn't a problem after that.
Burnt Out, ASN, RN
When I was pulled to another unit not too long ago, I was charting on my patients and I looked back at the previous days notes-Nothing by the day shift RN!
Generally on our unit, if there is nothing charted, we say "Hey, X, you forgot to chart!"
I think your co-workers need a reminder that "if it isn't charted, it isn't done."
Maybe everyone needs a reminder too that if there is a lawsuit against the facility, that those that are guilty of not charting might as well go hang themselves now... :uhoh21:
Ari RN, BSN, RN
My professor always told us to WYA!!!!!! [Watch Your A@$]
If you didn't document it, it was never done!!!!!
......"if it isn't charted, it isn't done."......:uhoh21:
I think some of the nurses may be trying to use this to their advantage. In other words, "If I don't chart the bad thing that happened, then there is no way to prove that it happened."
gwenith, BSN, RN
Actually they have it back to front. Although we are in diffferent countiries this is the same - when it comes to court in a criminal case you are innocent until proven guilty - in a civil case you are guilty until proven innocent. If a bad thing happened there is no way to prove that the patient is not telling the truth and therefor the patient will be believed over the nurses.
Not charting not only opens up problems in actual adverse events it also opens you up for litigation in a malicious suit. The suit could be a total fabrication (i.e. sexual harrassment) and because they have a history of NOT documenting they will have no credibility in court and they will go down - in BIG BIG flames.
I did a search of the forums to see what posters on other threads concerning failure to chart had to say. I found this thread, which is really relevent to the issue:
Wow. Did they miss the CYA portion of documentation. Do you have a medical records consultant? If so maybe they could provide some assistance. I don't envy your position of basically having to chart everything for them. Another option might be to discuss with your boss the possibility of continuing education in documentation. There are several good home study options they could obtain. Where I work there is always a nurse reviewing charts and after so many instances of having people backdate and late entry things they've become a lot better about documentation.
Create well-written care plans that meets your patient's health goals.
This study guide will help you focus your time on what's most important.
Choosing a specialty can be a daunting task and we made it easier.
By using the site, you agree with our Policies. X