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?
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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?