Did I handle this correctly?

[litlamp]

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?

[Valerie Salva, BSN, RN]

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.

[caliotter3]

I've encountered this many times, especially a treatment where I assess the patient and find the same dated dressing that I had placed on my previous shift. I chart the correct circumstances. The only exception would be if there is something that I can bring to the attention of another nurse on my shift, where he/she could make a correction or late entry. I would bring this to the other nurse's attention, otherwise, I simply chart it as I see it.

[morte, LPN, LVN]

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 am not talking about editing any thing....serial documentation would be a better way of say ing what i mean, perhaps.....there should be a way of entering that info into the flow sheet screen....in meditech , if you want to see the previous entry, you f5 and it comes up....this same sort of thing maybe what happened in this instance.....and the fact that you hadnt documented in that screen wouldnt look good for YOU either....no it is not you responsibility to do her/his assessments, but it is your resp. to do thorough charting

[litlamp]

i am not talking about editing any thing....serial documentation would be a better way of say ing what i mean, perhaps.....there should be a way of entering that info into the flow sheet screen....in meditech , if you want to see the previous entry, you f5 and it comes up....this same sort of thing maybe what happened in this instance.....and the fact that you hadnt documented in that screen wouldnt look good for YOU either....no it is not you responsibility to do her/his assessments, but it is your resp. to do thorough charting

I think I'm a bit perplexed being that we don't use meditech, however, when the information is entered the previous three entries are already visible to me at that time in the electronic charting system our facility uses. I documented in the flow sheet directly before and after her last entry, factually as required as of that timed entry.

I guess what I'm questioning is

...and the fact that you hadnt documented in that screen wouldnt look good for YOU either...

because this is where both of my entries were made.

.... or it could be that it's just too darn early and my neurons need a jump start this morning..

[patwil73]

I would say your charting was correct, but I do have one question - why didn't you just restart the IV? Is there a reason you have to wait for the doctor to determine if IV is ok to use or not?

Thanks

Pat

[NorthTexasNurse]

does your facility use cpsi? That's what we have and I hate it. It's like an excel spreadsheet with all of your assessment criteria down the side and the times of assessments going across.you can see everyones assessments while putting in yours pretty much with no extra steps. If u want to see their whole entry you can click it but it's mostly short answers as it's eight pages long.

[litlamp]

I would say your charting was correct, but I do have one question - why didn't you just restart the IV? Is there a reason you have to wait for the doctor to determine if IV is ok to use or not?

Thanks

Pat

The IV was KVO 30ml/h only for a q 24h antibiotic that the charge nurse changed to PO, and only required the doctor to sign off on it in the am.

[litlamp]

does your facility use cpsi? That's what we have and I hate it. It's like an excel spreadsheet with all of your assessment criteria down the side and the times of assessments going across.you can see everyones assessments while putting in yours pretty much with no extra steps. If u want to see their whole entry you can click it but it's mostly short answers as it's eight pages long.

Nope, but it is similar in set up. It's unlike excel in that there are check boxes with pop up choices and small areas for type in comments.

[NeoNurseTX, RN]

I see the previous RN chart that the patient is on room air or what not when they are on a vent.. and have been their whole shift. Just chart what YOU observe and cover your own booty. DON'T change their charting.