Dealing with co workers. what would you do?

[pinkfluffybunny]

Situation: Received pt from parents, noted bruise on forehead. Moc explained what happened. I did my assessment and documented, no neurological changes. Hours later on coming nurse, I give report and she freaks out. Insists I do an injury report, I explain it didn't happen on my shift hence no need. She wants to know did I report it, which I didn't because there is no change in pt condition. Trust me I am the first person that will wake a case manager at 3 am. She calls the case manager while I stand here. I explain to the CM. There is no problem. Skip to next shift, I read her notes and the first page is all about how I didn't do what I was supposed to and what I need to do. I am a little angry at this point. I feel slandered in a way because the way she presented it in her notes didn't reflect the actual exchange and everything said. Just the parts that that make me look incompetent. It was so unprofessional. I can't say anything to her bc I am sure she will put it on her notes. What to do?

[nursearoo]

Situation: Received pt from parents, noted bruise on forehead. Moc explained what happened. I did my assessment and documented, no neurological changes. Hours later on coming nurse, I give report and she freaks out. Insists I do an injury report, I explain it didn't happen on my shift hence no need. She wants to know did I report it, which I didn't because there is no change in pt condition. Trust me I am the first person that will wake a case manager at 3 am. She calls the case manager while I stand here. I explain to the CM. There is no problem. Skip to next shift, I read her notes and the first page is all about how I didn't do what I was supposed to and what I need to do. I am a little angry at this point. I feel slandered in a way because the way she presented it in her notes didn't reflect the actual exchange and everything said. Just the parts that that make me look incompetent. It was so unprofessional. I can't say anything to her bc I am sure she will put it on her notes. What to do?

I would call the CM you spoke to OR the director of the agency you work for..... did that nurse document this as her opinion or just what the facts were????? Anytime I have taken care of a patient who had any bumps, bruises, etc...if they happened when nursing was not present, I just documented in my notes exactly what was stated and by whom, then exactly what I observe, such as area, measurement, behavior etc.....In the end the bottom line depends on your agencies protocol for this.....if their protocal is report any injuries, then yes .......maybe check your company policy.........

[caliotter3]

Do your own writeup on a communication note and bring it to the agency. Request to meet with the case manager and/or the Director of Patient Care Services and present your side of the story, in writing and in person. They will take it from there.