Digs in her Progress Notes!

Published

More backbiting on the unit I guess. The deal is that it is a psych unit, and at no time on my watch did I witness any inappropriate behavior between two particular patients. So my progress note read : Pt calm, co-operative, interacting appropriately with others, blah blah, you know. Well the oncoming nurse wrote after me, "Contrary to what was written above, another RN warned to watch out for this patient being 'chummy' with another, and indeed, I caught them going into the dayroom at night'.

Am I being too sensitive, or was it a dig at me?

i don't think so. it sounds like she was just saying that her experience was different than yours. i do think that she could have just written what happened on her shift without the "Contrary to what was written above".

You are just supposed to write what you see - leave the politics and personal stuff out of it.

And things change shift to shift anyway.

I think she was inappropriate.

steph

Specializes in Med/Surg, Ortho.

I agree, needless. It would surprise me if she didnt get called in on this note herself. Her "evaluation" of your note has no legal use and she should be made to strike it from the charting, and remake the note appropriately. Just that simple. You are right if you didnt observe it, you cant chart it as such. You can chart about information recieved from another nurse, just not chart as if you observed it. That nurse needs a little brushing up on her charting skills.

Patient observed going into dayroom during NOC hours with .......

Requested individuals return to their respective rooms and not re-enter dayroom until within policy hours. (Or whatever the case).

I think it was inappropriate as well, and I would have taken it as a dig. Just because the patient acted one way on your shift does not negate your entry. She should have left off the "Contrary blah blah blah".

Specializes in ICU, Education.

Dig or not, she is the one who looks bad. "Contrary to what is written above" has NO PLACE in a chart. "just the facts mam".

I agree with all the posts. This nurse's charting is unprofessional, and so is her attitude.

Specializes in NICU, Infection Control.

Why, what a lovely co-worker!! Well loved by all, I'm sure.

NOT.

Keep thinking to yourself: Karma sticks like glue, and she's gathering a lot of BAD karma.

This is too deep for me-Pysch out the Psych nurse . Maybe we need a psych nurse to figure this one out for us . Any one out there?

Specializes in Psych, Med/Surg, LTC.

I don't understand how someone can chart on something that did/didn't happen if they weren't present. I would bring this up to your nurse manager. I also don't chart on another nurses pt unless asked to. Thats just messed up. It seems personal to me. I would assume they either have something against you or the pt. to do that kind of crap.

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