Published Feb 6, 2012
jensmomrn11
76 Posts
I am a fairly new RN, with about 1 year LPN experience prior. I found my first job in a sub-acute/LTC facility. This facility gives each RN between 18-22 patients, so you give meds, do tx., take off orders, do new admits, etc. all in a 12 hour period, and if you stay over, you can get written up for overtime. I have only been out on my own for about 2 weeks now and this past weekend, I feel like a total idiot. I am afraid that they are going to call me into the office. I had a skin tear and a new admit plus all of the other days disasters and when I went to put the information into the computer, I don't know if it was me or the computer, but had trouble entering my information. I was in the middle of documenting the new admit assessment in the computer when I was called into a patients room. When I came back to the computer, it would not let me continue so I started a new page and entered all the information. I am afraid that they will not be happy that there is a completed assessment and then a half completed assessment in the computer. When I went to do the incident report for the skin tear, I again had trouble, the computer would not let me advance past the first page. So again I started a new one and this one went through. The place where I work is very particular over the paperwork and I am afraid that this is going to go against me. Also, by the time I got the incident report done, the aide that found the skin tear had left (the aides work 8 hours, the nurses 12) and I did not get her to fill out her statement. I left the report in the 24 hour book plus passed along in report that the aide needed to sign a statement. Again, I am afraid that this will go against me because I did not get it done while the aide was still there. They don't want to hear that the day was busy and the time just gets away from you (especially when you get a new admit who should be going into hospice and not rehab, but that is a different story). As an LPN, we were not allowed to do new admits and I have been getting compliments from both nurse managers on my assessment paperwork up until this point. I have also had compliments from therapy and the other nurses, so am I just being a nervous nelly or am I in trouble?
ac3070
30 Posts
My advice comes with the disclaimer that I haven't started my RN job yet, but...
Can you ask for some help re: computer charting? You be the big one, mention that you've had some problems, this is the problem you were having, do they have any tips to keep it from happening again? That way you are both bringing up the problem and hopefully finding out how to fix it.
As far as the skin tear--you did what you could re: the aide; I wouldn't worry about that part of it. She should have known she had to do a statement (right?) so that onus should fall on her. You documented to the best of your ability.
I had charted admissions before and incident reports before and did not have any problems.
I don't know if it was a computer issue or if I was just so flustered over the acuity of the patient that
they sent to us and my brain just stopped working. There was no supervisor on when I left or else I would have
talked to somebody then. I am off for the next couple of days and will speak to somebody when I work again.
As for not getting the Aide's statement, I take resposiblity for that. I should have made sure I got her statement
before she left, but when all heck breaks loose, you can only do so much at one time. At least I am the type of person
that trys my best to learn from my mistakes and am not likely to make the same mistake twice.