Question for the RN's....

[nursejessica2013]

Hi there to all out there! First let me say that I have been viewing this website for quite some time and have learned quite a bit from you all but I have a question that may create some buzz.

I am currently a nursing student with one more year to go (thank goodness) and work as a PCA at a hospital in Houston, Tx. When I arrived to work the other night, I learned that computer system was down and would not be back up until morning (12 hours with no computers, it was a madhouse!) I had taken vitals for 16 patients but was unfamiliar with the hand charting process so it took me a little time to document the vitals. Well when I got to my last 6 patients, the vitals had already been charted...but they were not the values that I had, they were completely opposite.

I went and asked the RN about the vitals that were noted and she looked at me like I was stupid and didn't answer me. At least two patients had temperatures that were in the low 100s but she documented them and 98F!

I felt like if I was taking too long for her then she should have either told me or showed me how to use the form (I had never seen it) or either come and asked for the vitals but not record numbers that were not accurate, the many what-ifs popped into my head.

Not wanting to start anything I didn't say a word but I really feel that false documentation is not a good example for someone like myself who is currently going through nursing school.

What do you all think?

[Katnip, RN]

You could have just gone ahead and taken the vitals anyway and documented what you got.

Of course, that would open up a lot of questions from the following nurse. Or should.

Hopefully the following nurse or PCA took accurate readings and recorded them when they came on to work.

[wooh, BSN, RN]

So you have any proof that she made up the numbers as you seem to be inferring? Could she have possibly taken them herself and just got different numbers than you?

[TazziRN, RN]

I would have recorded what vitals I got. That way, if the question comes up about making up numbers, the fingers won't be pointed at you.

[savedbutterfly]

Always record what you get

[nursejessica2013]

So you have any proof that she made up the numbers as you seem to be inferring? Could she have possibly taken them herself and just got different numbers than you?

I wrote all of my vitals down and when compared to what she wrote the were not close, plus when I asked her she ignored my question and looked at me crazy and knowing the RNs on my floor (night shift) any thing they need they will ask a PCA even if its something they could while they are in the room. So I seriously doubt that she had the time to take them herself in with how crazy they were running around.

Also I am not trying to turn this into another PCAs vs. RNs. But as a future RN (2007) I wonder was this just a short-cut technique?

[Agnus]

Always record what you get

Yep.

Two nurses may assess the same patient and have different assessments. Always record what you got. This does not necessairly mean someone's is wrong.

[cant_not]

ahhh... I hate to out-right say this, but if you ever work in LTC you’ll see nurses do this a lol (if she actually did fake the vitals) I wouldn’t recommend it, I’m no ‘whistle-blower’ but I’ve actually reported people for doing it. The reason they are called ‘vitals’ is because they are VITAL..... I can’t stress that enough.

Also, she could really get into quiet a bit of a trouble falsifying charts. My aunt actually got caught falsifying blood sugars; her license was suspended for 6 months, and she now works under a disciplined license (some employers wont hire you with this on your license.) It prevented her from going on to get her RN, she applied to two different programs and both denied her acceptance because of this.