Dressing documentation

Published

What happens if you documented a dressing change but the patient states it didn't happen. I'm pretty sure that I changed it but now I'm questioning myself. I did forget to date it's the patient's word against mine.

Up Vote Up Vote ×
Specializes in VA-BC, CRNI.

Assess the dressing, does it look like it was just changed? What is the risk/benefit to changing or maintaining the dressing?
Since you did not document the dressing and are doubting yourself it isn't your word versus the patient's, it's just the patient's word against doubts. 

Up Vote Up Vote ×

I documented that I changed it. But the next day, my manager calls me on my day off and informs me that the patient reported that I did not change it. So that's the issue. I am doubting myself now and wondering if this might be considered falsifying records if they believe the patient over me. I am a new nurse and very nervous.

 

Up Vote Up Vote ×
Specializes in VA-BC, CRNI.
Shannon Moss said:

I documented that I changed it. But the next day, my manager calls me on my day off and informs me that the patient reported that I did not change it. So that's the issue. I am doubting myself now and wondering if this might be considered falsifying records if they believe the patient over me. I am a new nurse and very nervous.

 

Ah, makes sense. 

Typically falsifying records involves the deliberate or intentional altering of records, not mistakes. Mistakes happen. I am sure you know this but this is where documenting on the actual dressing can help prevent misunderstandings in the future. 

Up Vote Up Vote ×
Specializes in orthopedic/trauma, Informatics, diabetes.

depending on how long pt's have been in the hosp or if they have had surgery/pain meds, they forget a LOT. Can't believe a manager would believe a pt over a nurse that had documented. I had an issue once with a pt who said that I didn't give pain meds. I did, I scanned them. The pt's family member was like "I didn't see you give any pain meds to my sister"  I freaked out. From then on, I made another nurse come in and watch me give them. Pts will try to get you in trouble, they forget, they are manipulative (like my pt that wanted more opioids). 

Best thing is to try and remember to label your dsgs 😉 

1
Up Vote Up Vote ×
Specializes in Vents, Telemetry, Home Care, Home infusion.

Had this happen to me once--since employee in good standing, nothing further happened. Going forward, a black magic marker was ALWAYS in my nursing organizer and double checked dressing marked when changed; also marked fentanyl/nitro patches for same reason. One of many future nursing lessons.

HUGS to you. 

1
Up Vote Up Vote ×
+ Join the Discussion