Correct documentation

Nurses LPN/LVN

Published

  • by Chanta2
    Specializes in Home births.

OK, I have this situation at work. I work with a nurse who always document in the chart what the next nurse forgot to do. Omissions, eye gtts. The kind of stuff my supervisor should be handling, if she audit the MAR/TAR. I find her documentation very foolish and not legal. I want to know have you ever encountered a nurse that actually get away with this type of behavior. I have addressed this with my immediate supervisor, I have not seen anything be done about it. I have communicated with my supervisor that I want to only communicate on the 24 hour board and verbal reports at shift change with her so that we can have a professional relationship only. I feel so uncomfortable working with this nurse. I am not perfect. I just do my job. Pass my meds. Do my tx. F/U on previous shift work, etc. She is the kind of nurse that acts as though she is the only one that can get the job done! She is so wrong, as to say in everyone's job, there are the strong team players, and the so-so team players. I pull my weight by all means. I always complete my assignments, do not leave my work for the next shift. Call in my labs, Rx orders, notify family/MD in a timely and efficient manner. No matter how well I think I cover my shift. She will seem to find something for me to do the next day that she has looked into if she was off for a day or so and I'm stuck doing her projects. I hate working with this nurse. I have wrote her a letter and told her she is behaving the cliche' nurses eat their own, young,' it all fit her description. I am feed up with her!:down:

morte, LPN, LVN

7,015 Posts

if you work coporate, go up the chain of command right to the DON.....including risk management. unless she is your boss ,why are you doing "little projects" for her? good luck

sasha2lady

520 Posts

Specializes in LTC.

I am with you....i dont think that documenting what another nurse didnt do is correct.....this is one that kills me...ive taken report from a certain nurse who has documented this line here in her note "Reported lab to second shift nurse. Second shift nurse to call MD tonight."....now..it just so happened i was that second shift nurse and that lab was never told to me....the lab as a matter of fact was thrown up in the MD box for him to look at the next day and had I not had to document on that particular pt i wouldnt have seen it. So I had to look at that lab and it was normal..so i had to chart that the lab was wnl and put in the box for md to review in the am....they have done that to me several times. i was always taught never to chart that kind of stuff....it opens up all kinds of legal stuff should that go to court. now..what would have been bad is if i hadnt seen that note and looked at that lab....or that i hadnt had to chart on that pt at all....i wouldnt have wrote anything so a state surveyor or a lawyer couldve read it and been like hmm.....why didnt either nurse notify the md if this was abnormal cuz thats the way she made the note sound when she wrote it. and i dont ever put anything like "......will notify nurse on next shift of ....." b/c thats not factual...that just says you intend on it...it doesnt state that its something you actually did. in the meantime....tell that nurse to complete her own projects or see if you cant work a different assignment for a while.

caliotter3

38,333 Posts

I worked with a nurse who wrote up incident reports on med errors that she "created" for other nurses. She would call the doctor and the family and run right to the DON with her sizzling info. Her entire shift consisted of going up and down her hall and finding everything that the previous shift did not do, or did not do the way she wanted it done, and run right to the DON. I always thought it was dangerous for her to be charting on these little backstabbing episodes. Although everyone was aware, including the supervisors, nothing was done because she was supposed to be the fair haired girl of the DON. Finally, she got fired when one of her set ups backfired, and she caused the death of a patient. Nobody wanted to be around her. You could hear the sighs of relief when she got what was coming to her. Hang in there. You can never let your guard down around backstabbers and trouble makers. Hopefully, she will leave sooner rather than later.

pagandeva2000, LPN

7,984 Posts

Specializes in Community Health, Med-Surg, Home Health.

What this nurse is doing equates to negative charting...you are supposed to chart what you see, what was done, not what was not done. To me, that is Nursing 101. Behaviors like this annoy me to no end.

systoly

1,756 Posts

Specializes in LTC, Memory loss, PDN.

I'd ask her why she wants the facility to fail the next state inspection. This falls into the you don't pee where you eat category. The DON needs to be made aware of this, however, in a matter of fact way. Once the DON is made aware of this, it's out of your ballpark. As for the other nurse, caliotter3 is right, they sooner or later dig their own hole. But why are you doing her projects? After all, she's the one that pointed out you need to concentrate all your efforts on your own job so omissions can be eliminated.

pagandeva2000, LPN

7,984 Posts

Specializes in Community Health, Med-Surg, Home Health.
i'd ask her why she wants the facility to fail the next state inspection. this falls into the you don't pee where you eat category. the don needs to be made aware of this, however, in a matter of fact way. once the don is made aware of this, it's out of your ballpark. as for the other nurse, caliotter3 is right, they sooner or later dig their own hole. but why are you doing her projects? after all, she's the one that pointed out you need to concentrate all your efforts on your own job so omissions can be eliminated.

:yeah::up: excellent reply! one to use the next time she creates projects for you to do...

Chanta2

37 Posts

Specializes in Home births.

Update. My DON did address the matter. I worked last night and I did NOT do one of her projects she left for me to do. I passed it on to the next shift!

She wanted a weight and height done on one of her admissions!

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