was this handled right?

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Graduate nurse here, only working a few weeks....

Yesterday, I had a pt on Q4 vitals, due at noon. I was doing my physical assessment around 12:30 and asked the pt if anyone had been in to do her blood pressure and temp yet this afternoon. (In our facility techs usually do the vitals but nurses are responsible to see that they are done). THe pt said no, so I told her I'd be right back with a b/p cuff to get them. On my way out, I grabbed pts bedside chart where all the flow sheets are. I decided to fill in the flow sheet on my assessment first, so as to be sure that I didn't forget anything (so I could get what I forgot when I went back in to do vitals) I noticed that the vitals were filled in. It was 12:40 at this time. The time given for the vitals was 1300. So I went 'huh' and brought chart to my preceptor.

Preceptor reviewed the chart, noted the times and suggested I go back in and question the pt a bit more. So I did. Pt stated no one had done her vitals since the morning. Pt is alert, oriented and on no meds (post partum) so the question of the pt being confused is small.

So preceptor and I went to the tech responsible and asked her about it. She said yes she did the vitals. We looked at tech's record sheet and checked the vitals she'd written on it against what was charted--they matched except O2 sat was written on chart and not on tech's record sheet. We told her that the time was charted wrong and that we were worried maybe she wrote the wrong pt's assessment in the chart. Tech felt pretty strongly that she wrote said pt's vitals in right chart. It was all very nice, professional. No assumptions, no accusations.

next preceptor and I went to charge nurse and pulled her aside privately and showed her the chart, noted the time, and explained our talk w/ the tech. Charge said tech was experienced, came to us from a diferent floor but she would talk to her.

I returned to my pts room to collect a new set of vitals and document them. Preceptor spoke with the tech, explained that we didn't want to come across as accusatory or whatever but that we were just worried someone else's vitals got charted wrong, and that would mean that someone else wouldn't have vitals charted, but that the nurse responsible would eventually figure it out.

A bit later, the tech came up to me and told me that she is having a hard time with military time, and that she must have done the vitals at noon, but wrote 1300 since she was confused over what time it was.

I told her that we all have trouble learning military time, its understandable etc. We kind of laughed and commisserated about learning military time and left it all at that.

***

Ok, I know you don't make assumptions. But someone who has worked at the hospital for a couple years should know military time. And I know that the vitals were not done at noon because the pt was at a class and didn't get back to her room til a bit after noon. Now maybe the tech used noon in a broad sense...anytime between 12 and 12:30....

I am uneasy about it. I feel that I may have caught someone making up numbers. Maybe not. It just isn't sitting right with me. But charge knows about it, its out of my hands. Right?

Does it sound like we handled it right?

And what would you do now if the tech was assigned to your pts? I try to get the vitals myself but there are only 2 or 3 bp machines on the unit and the techs have them in use to to am and pm vitals, so its not always something I can get to before the techs do. Should I just watch and wait? Or let it go? or what?

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Specializes in ICU, CVICU.

Ok..this is not a professional opinion or anything because I am not a nurse (yet) but it seems to me that you are weighing the word of an experienced technician against a patient who may be alert but is probably overtired and not at all focused on what is going on around her. I know when I was postpartum I probably could not have told you if i'd even seen a nurse or when- know what I mean. I guess i'm saying watch her- but also give her the benefit of the doubt. Although it is pretty hard to mess up 12:00 in military time :)

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Ok..this is not a professional opinion or anything because I am not a nurse (yet) but it seems to me that you are weighing the word of an experienced technician against a patient who may be alert but is probably overtired and not at all focused on what is going on around her. I know when I was postpartum I probably could not have told you if i'd even seen a nurse or when- know what I mean. I guess i'm saying watch her- but also give her the benefit of the doubt. Although it is pretty hard to mess up 12:00 in military time :)

I agree with the benefit of the doubt. The pt was day 3 s/p c-sect, no pain med on board. baby slept in nursery all night.

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Specializes in Med-Surg, , Home health, Education.

I would just watch and wait. Also, don't you have access to manual BP cuffs? Sometimes that is a concern that nurses/ CNA's etc rely too much on "Machine" availability and don't check manual BP's. If I get a BP that doesn't seem right I always double check it against a manual. I trust my eyes and ears a lot more than that machine. You did the right thing about notifying the Charge and your preceptor. Is the tech possibly working a different shift than usual and is mixed up on military time?

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How closely the vital signs you took, corolated with the vital signs recorded by the tech, might help you figure things out. Definitly a 'watch' is in order for this tech. This is one reason I prefer primary care, I absoloutly KNOW my VS were done as recorded.

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Okay, maybe the pt did get confused.........BUT THE TIME WAS WRONG. Sorry, anyone who has been in the business for more than a few months knows military time. Not only that, anyone with experience also knows that we chart down to the minute, not write 1200 when something actually happened at 1215.

Nothing you can do right now except take the explanation and keep an eye on this tech. Either she lied and kind of got caught and will never do it again, or she lied and will lie again and needs to get caught. Either way, document this incident.

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I would just watch and wait. Also, don't you have access to manual BP cuffs? Sometimes that is a concern that nurses/ CNA's etc rely too much on "Machine" availability and don't check manual BP's. If I get a BP that doesn't seem right I always double check it against a manual. I trust my eyes and ears a lot more than that machine. You did the right thing about notifying the Charge and your preceptor. Is the tech possibly working a different shift than usual and is mixed up on military time?

We don't have many manual b/p cuffs and the irony is that they are kept w/ the bp machines lol. We don't have them on the walls in the rooms. I don't know anything about hte tech except what I posted. NOt sure about her regular shift.

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How closely the vital signs you took, corolated with the vital signs recorded by the tech, might help you figure things out. Definitly a 'watch' is in order for this tech. This is one reason I prefer primary care, I absoloutly KNOW my VS were done as recorded.

That is a good point about the vs correlation. The respirs were off--I got 18, she got 16 which were the last several respirs collected. Most everything else was similar.

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Okay, maybe the pt did get confused.........BUT THE TIME WAS WRONG. Sorry, anyone who has been in the business for more than a few months knows military time. Not only that, anyone with experience also knows that we chart down to the minute, not write 1200 when something actually happened at 1215.

Nothing you can do right now except take the explanation and keep an eye on this tech. Either she lied and kind of got caught and will never do it again, or she lied and will lie again and needs to get caught. Either way, document this incident.

How do I document it? I told the charge nurse and she said she would talk to the tech. I re-did the pts vitals at 1310 and put that time on the flow sheet. It looks of course like the vs were done 10 mimutes apart. I DON"T like that the techs don't have a place to initial/sign off on the flow sheet.

edit: we talked w/ the charge about charting the correct time. NOt just putting 1300 for all the vitals done between 1300 - 1400, for example. Because it can throw our times/assessments off too, if we think something is done at one time and it was really done at a different time.

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I think you handled it pretty well. IF the tech has been being sloppy, this event will certainly remind her to do a better job in the future.

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How do I document it? I told the charge nurse and she said she would talk to the tech. I re-did the pts vitals at 1310 and put that time on the flow sheet. It looks of course like the vs were done 10 mimutes apart. I DON"T like that the techs don't have a place to initial/sign off on the flow sheet.

If the techs have no place to sign off on the flow sheet, then they shouldn't be writing anything on the flow sheet. If you are the one signing off on everything that's documented on your shift, you should be the only one documenting. They should be documenting on a worksheet and you should be transcribing only that information that you are willing to sign.

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If the techs have no place to sign off on the flow sheet, then they shouldn't be writing anything on the flow sheet. If you are the one signing off on everything that's documented on your shift, you should be the only one documenting. They should be documenting on a worksheet and you should be transcribing only that information that you are willing to sign.

exactly. I am going to look around some more; being new, perhaps there is a place that I missed.

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