Did I handle this correctly?

I would have done exactly the same as you.

Sounds fine to me.

Thank you!!

(((sigh of relief))) :)

Chart what you assess or your intervention. It reminds me of certain circumstances, ex: I look at previous neuro assessments on my patient with a rt pupil of PERRL at 3mm - kind of difficult when the patient has a glass eye.

Just chart what you do/find and you can't go wrong.

Let me know if you would have done this differently please...

I had a patient whose IV was not infiltrated but at the point of access was showing irritation. I reported to my charge nurse and she assisted me with removal and assessent of the area herself. She said to leave the IV out until the doctor assessed her in the AM. (it was KVO 30ml/h) I charted everything accurately in my nurses notes.

I reported this to the next shift, in detail.

The following day I had the same patient. (doctor had not been in yet)While entering my flow sheet which is basically a head to toe assessment and in a different window from nurses notes (computerized charting) I noticed that the night shift stated the patient still had her IV and it was infusing at 30ml/h!! When you enter your assessment you can see the previous three entries at the same time, I "assume" she may have just copied what the previous entry was? My assessment was in the morning and prior to IV removal. We only do 1 of those flow sheets per shift, all other info is in the nurses notes.

So, I entered on the flow sheet that she had no IV, it was removed at ___ as stated in report on ____. I also let my preceptor know.

I know it may send trouble that nurses way, but I didn't see to do it any other way. What would you have done?

you absolutely handled it correctly.....I would have done the same.

I would have done exactly as you did--chart what I did and what I observed and assessed. Isn't it sad to discover the incompetency of others?

Yes it is sad and disheartening to see this happen. I've learned mostly through this forum and on my own that no matter what others may do, my actions as a nurse must stand alone. I know I am my patients advocate and as long as I do what I know is right than I can sleep at night, even if it may get a peer into trouble.

the only computor charting that i am familiar with is meditech, and in that system, what you would do is go back into the flow sheet (process intervention) and take out the iv.....

i would have done the same, being a new nurse myself i understand where you're coming from, it's not always the best thing to tread on someone's toes, but if people are incorrectly charting things then that can lead to dangerous outcomes. You did the right thing, and that's all that matters!

the only computor charting that i am familiar with is meditech, and in that system, what you would do is go back into the flow sheet (process intervention) and take out the iv.....

We use a different application. Entries are made with your personal login. After your digital signature upon completion, the entry is locked and uneditable. I couldn't change another nurses electronic charting just as I couldn't change their handwritten charting. I'm still new to the system myself so perhaps there is a way to do a "late entry" but again, that would be something she would need to do.

I have followed nurses who have charted "pos bilat pedal pulses" on a pt who only has one leg.

I've followed nurses who have charted the characteristics of a wound, and signed off the dsg change in the tx book. Then I go and see that the dsg with the date and my initials on it from the last time I worked is still in place.

Unfortuately, this stuff if fairly common. Just always remember to CYA.